Archived: Susan Mary Horsewood-Lee - Oakley Street

We carried out an announced comprehensive inspection on 27 April 2018 and 10 May 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.

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.

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 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.

Prior to our inspection, patients completed CQC comment cards telling us about their experiences of using the service. Eighty-one people provided wholly positive feedback about the service. Dr Horsewood-Lee was described as caring, attentive and efficient.

Our key findings were:

• There were arrangements in place to keep patients safeguarded from abuse.
• There was minimal evidence that the service assessed and managed risks so that safety incidents were less likely to happen; a number of health and safety and premises risk assessments had not been carried out.
• The premises were clean and hygienic; however, no infection control audits of the service environment or infection control training of staff had been completed.
• There was minimal evidence of suitable arrangements for assessing and managing fire risk.
• Procedures for managing medical emergencies, including access to emergency medicines and equipment, was not safe. There were limited arrangements to identify, learn and improve where things had gone wrong. There was a policy for reporting incidents, however in some cases, these arrangements required a review in order to ensure that they effectively mitigated all risks.
• There was some evidence that the provider acted on safety and medicines alerts. However, the service did not have a process to manage patient safety alerts. There was no record kept of the action taken in response to patient safety alerts, and the service was unable to demonstrate that they had an effective process to manage these.
• The service delivered care according to evidence-based guidelines; however, they did not have processes in place to monitor how guidelines were followed.
• The service had a number of policies and procedures, most of which had not been reviewed and updated to reflect day to day practice in the service.
• Governance arrangements were not in place to ensure effective oversight of risk. There was minimal evidence of processes to monitor and improve quality and identify risk.
• There was some evidence of systems to improve quality of care and treatment for patients.
• The provider had a system for managing written complaints.
• Patients found it easy to access appointments with the doctor.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient feedback for the services offered was consistently positive.

We identified regulations that were not being met and the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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 the need to have a written policy in place covering fitting contraceptive devices including managing complications after coil insertion.
• Review the need to carry out a formal written assessment, which is kept under review, to identify which emergency medicines it is and is not suitable for the practice to stock, and to keep appropriate records of checking expiry dates of those medicines.
• Review the need for arrangements to assist patients with communication needs.
• Review the need for guidance on checks of patient identity and, where appropriate, the responsible adult’s identity.
• Review the need for a structured quality improvement programme that monitored the effectiveness of changes made to the service provided.