Archived: London Women's Clinic

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Kent Fertility as part of our inspection programme of a new provider registration for the service. This was a first rated inspection for the service that was registered with the Care Quality Commission (CQC) in November 2021. During this inspection we inspected the safe, effective, caring, responsive and well- led key questions.

Kent Fertility is an independent provider of fertility services, located in Bromley Kent. 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. These include pregnancy scans (post 12 weeks) and a range of women’s health and gynaecological consultations and procedures, such as hysteroscopy. (A hysteroscopy is a procedure used to examine the inside of the uterine cavity).

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. Kent Fertility provides a full range of fertility services for NHS and private patients and holds a licence with the Human Fertilisation and Embryology Authority (HFEA) to enable them to carry out this work. Fertility services provided are not within CQC scope of registration. Therefore, we did not inspect or report on those services.

Kent Fertility is registered with the Care Quality Commission to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening procedures; Surgical procedures.

The service’s managing director is the registered manager. 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:

• There was a lack of records to demonstrate that recruitment checks had been carried out in accordance with regulations for some staff.
• The monitoring and storage of staff documentation was not well managed and did not ensure leaders had clear oversight of their status.
• Arrangements for chaperoning were effectively managed.
• There were some processes to assess the risk of, and prevent, detect and control the spread of infection. However, staff records of immunisations were not monitored in line with current guidance.
• Record keeping for the use of ultrasound probes were not effectively kept in line with best practice guidance.
• There had been insufficient action taken to address and manage identified risks associated with Legionella bacteria.
• Mop heads and handles were mixed up.
• There were appropriate arrangements to manage medical emergencies and suitable emergency medicines and equipment were in place.
• Clinical record keeping was clear, comprehensive and complete, and in line with best practice guidance.
• There was effective and open communication and information sharing amongst the staff team.
• There were regular team meetings and staff felt motivated to contribute to driving improvement within the service.

The areas where the provider must make improvements as they are in breach of regulations are:

• 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review Sepsis awareness training for non-clinical staff.
• Review audits undertaken to demonstrate quality improvement for patients.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services