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Inspection Summary


Overall summary & rating

Good

Updated 20 September 2019

This service is rated as Good overall. (Previous inspection November 2019 – 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 at Dr Talha Shawaf Clinic as part of our inspection programme.

Dr Talha Shawaf provides gynaecological and reproductive medicine services for adults over the age of 18. The services include consultation on fertility care, investigations and treatments including In Vitro Fertilisation (IVF), pre and early pregnancy care, menopause and gynaecological conditions. Patients having IVF treatments are referred to a Human Fertilisation and Embryology Authority (HFEA) licensed centre for the surgical procedures where Dr Shawaf works under practising privileges (the granting of practising privileges is a well-established process within independent healthcare whereby a medical practitioner is granted permission to work in an independent hospital or clinic, in independent private practice, or within the provision of community services).

Dr Talha Shawaf 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.

We received 12 CQC comment cards, all of which were positive about the service. Patients described the provider as highly professional, friendly, respectful and informative.

Our key findings were:

  • Systems and processes were in place to keep people safe.
  • The provider was aware of current and relevant evidence based guidance and they had the skills, knowledge and experience to carry out his role.
  • The provider did not audit clinical outcomes however In Vitro Fertilisation (IVF) success rates were independently monitored on an annual basis.
  • Patients who used the service had an initial consultation where a detailed medical history was taken from the patient. Patients and others who used the service were able to access detailed information regarding the services offered and delivered by the provider.
  • The website for the service was very clear and easily understood. In addition, it contained information regarding treatments available and fees payable.
  • Patient satisfaction with the standard and quality of services received was high.
  • The clinic had processes in place to securely share relevant information with others such as the patient’s GP and when required, safeguarding bodies and private healthcare facilities.

The areas where the provider should make improvements are:

  • Continue to review necessary training requirements and establish when training is required to be refreshed.
  • Review arrangements to be assured that health and safety systems are being undertaken and audited appropriately.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 20 September 2019

We rated safe as

Good because:

Safety systems and processes

The service

had 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 locums. 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.
  • The service had systems in place to work with other agencies, if required, to support patients and protect them from neglect and abuse.
  • The provider did not employ staff but provided evidence of a Disclosure and Barring Service (DBS) check for himself and for the secretary and personal assistant who were both self employed. (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 persons who may be vulnerable).
  • Staff received up-to-date safeguarding and safety training appropriate to their role. On the day of inspection the provider evidenced that they had completed Safeguarding adults training appropriate to their role. At our last inspection in November 2017 we found that the provider had not undertaken safeguarding children training and informed them that they should complete this in accordance with intercollegiate guidance. At this inspection we found that the provider had not undertaken safeguarding children training. Following this inspection the provider confirmed they had completed the relevant safeguarding children training and provided a certificate confirming this. Receptionists employed by the host location had completed safeguarding training relevant to their role.
  • The clinic had a chaperone policy in place. There were notices displayed in the waiting room to advise patients that chaperones were available if required. We saw records of patients being offered a chaperone during consultations including intimate examinations. Records documented if the offer of a chaperone was declined. Nurses employed by another provider at 64 Harley Street acted as chaperones for the clinic. The provider had assured himself that the nurses had received chaperone training and a Disclosure and Barring Service (DBS) check.
  • There was an effective system to manage infection prevention and control undertaken by the host location. At our inspection in November 2017, we informed the provider that they should review the arrangements for monitoring infection prevention and control standards. At this inspection we saw that the provider did not have access to the host locations infection prevention and controlled systems or audits. Following this inspection we saw a copy of an infection prevention and control audit undertaken by the host location in October 2018, it demonstrated 94% adherence to National Institute for Health and Care Excellence (NICE) quality standards and that any required actions had been completed.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • Environmental risk assessments had been undertaken, which took into account the profile of people using the service and those who may be accompanying them.
  • There was a system in place for dealing with pathology results. Pathology specimens were sent to a professional laboratory for analysis. Once returned to the provider they were acted on within 24 hours. There were no outstanding results on the day of our inspection. The provider followed Human Fertilisation and Embryology Authority (HFEA) guidelines for processing abnormal test results.

Risks to patients

There

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

  • 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 to deal with medical emergencies which were stored appropriately and checked regularly. If items recommended in national guidance were not kept, there was an appropriate risk assessment to inform this decision.
  • We saw evidence that the host location maintained fire safety systems and equipment and they carried out regular fire alarm tests. Staff from the clinic were aware of evacuation procedures and routes.
  • There were appropriate indemnity arrangements in place and was registered on the GMC and performers list.

Information to deliver safe care and treatment

The provider

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.
  • Patients records were stored electronically and were encrypted to ensure they were safe and secure and adhered to data protection legislation. The provider was able to access patient’s records remotely on devices which were also encrypted.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

The provider did not hold any medicine stocks at the clinic.

  • The provider had signed up to receive patient safety alerts from the Medicines and Healthcare Regulatory Agency (MHRA). There were no examples of alerts being acted on as we were told none had been relevant.
  • All prescriptions were issued on a private basis by the provider. Once a prescription was issued it was scanned into the computer system.
  • The provider did not prescribe any controlled drugs.
  • There were effective protocols for verifying the identity of patients.

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.
  • There was a system for receiving, reviewing and actioning safety alerts from external organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA).

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system in place for reporting and recording significant events. The provider had systems and processes in place to identify, record, analyse and learn from incidents and complaints. The provider was able to share how these processes would work should a significant event take place. There had not been any significant events recorded for the services registered.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents


Effective

Good

Updated 20 September 2019

We rated effective as

Good

because:

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 the clinician assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service was involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The provider did not collect and monitor information on care and treatment. However, the providers IVF success rates were independently monitored on an annual basis by CARE Fertility London. Results for 2018/19 showed a live birth success rate of 50% when frozen embryo replacement had been undertaken, and 46% when fresh embryo replacement had been undertaken.

Effective staffing

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

  • The provider did not employ any staff therefore there was no induction programme or appraisal system in place other than appraisal and revalidation for the consultant.
  • We saw evidence of Continual Professional Development (CPD) completed by the provider.
  • The provider had a current responsible officer. (All doctors working in the United Kingdom are required to have a responsible officer in place and required to follow a process of appraisal and revalidation to ensure their fitness to practice). The provider was following the appraisal and revalidation processes.
  • At the time of inspection we saw that the provider had completed some necessary training which included safeguarding adults and basic life support. The provider did not have a policy which identified what necessary training was required and when training should be refreshed. Following this inspection, the provider sent us copies of training certificates, undertaken after the inspection which included; Equality and Diversity, Safeguarding children, Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, Information Governance, Infection prevention and Control and General Data Protection Regulation (GDPR).

Coordinating patient care and information sharing

Staff worked

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

  • The provider worked with a range of other services to provide patient centred care. For example, the provider had a close working relationship with Human Fertilisation and Embryology Authority (HFEA) licensed reproduction centres. The provider also had access to other specialist doctors, laboratories, imaging and a wide variety of complementary therapists ranging from acupuncture to nutrition.
  • The provider liaised with NHS GPs when necessary. The provider told us he asked for consent to contact the patients GP at the initial consultation and did so where appropriate. We saw records to show that GPs had been informed where appropriate.
  • Before providing treatment, the provider ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • 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.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Patients were signposted to a range of complimentary therapists including nutritionists, reflexology and talking therapies.

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.

Caring

Good

Updated 20 September 2019

We rated caring as

Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We received 12 completed Care Quality Commission comment cards which were all very positive about the service provided. We were not able to speak with any patients directly at the inspection.
  • 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.

Involvement in decisions about care and treatment

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

  • We were told that any treatment including fees was fully explained to the patient prior to their appointment so that people could make informed decisions about their care. Information about fees was available in the patient leaflet and on the website.
  • The provider told us interpretation and translation services could be made available for patients who did not have English as a first language, and for patients who had a hearing impairment. Service leaflets could also be made available in large print and easy read format for patients with a learning disability or visual impairment.
  • 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.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 20 September 2019

We rated responsive as

Choose a rating

because:

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.

  • Access to the clinic was not suitable for disabled patients as the treatment room was not on the ground floor. However, the provider had an agreement with another health care provider at the premises, to use a ground floor consultation room for patients who were unable to negotiate the stairs.
  • The provider told us that they had access to translation services for those patients whose first language was not English and the provider spoke Arabic and could therefore support Arabic speaking patients.
  • There was a hearing loop available at reception to aid those patients who were hard of hearing.
  • Information about the clinic including services offered was on the clinics website and information leaflets were available.

Timely access to the service

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

  • The provider told us that the clinic did not have fixed opening and closing times. He offered flexible appointments based on patient demand over six days a week. Appointments were managed by the providers secretary. The provider consulted with, an average of 10 patients a week.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded/did not respond to them appropriately to improve the quality of care.

  • There was a policy and procedures in place for handling complaints and concerns.
  • The provider was the designated responsible person who handled all complaints in the clinic. A complaints leaflet was available on request and information on how to complain on the clinic website.
  • The provider had not received any complaints in the last 12 months.

Well-led

Good

Updated 20 September 2019

We rated well-led as

Choose a rating because:

Leadership capacity and capability;

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

  • The provider had the experience, capability and integrity to deliver the service’s strategy and address risks to it.
  • The provider was responsible for the organisational direction and development of the service along with the day to day running of the clinic. They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

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 vision was to keep up to date with new developments in the field to provide the best quality service possible. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service monitored progress against delivery of the strategy.

Culture

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

  • The service focused on the needs of patients.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

Governance arrangements

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

  • Most 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. However, we found that there were shortfalls regarding some governance systems, for example;
  • The provider had not completed all necessary training requirements and did not have a training policy to establish what necessary training was required and how frequently it needed to be refreshed.
  • The provider was not able to demonstrate that they were assured that health and safety systems and checks had been undertaken. For example, fire safety checks and infection prevention and control processes had been completed by the host location.
  • The provider 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 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.
  • There were appropriate arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. For example, health and safety risk assessment had been completed by the host location including fire and legionella.
  • External audit was used to monitor quality. For example, IVF success rates were monitored on an annual basis by CARE Fertility London.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • 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. There were plans to address any identified weaknesses.
  • 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.

  • The clinic had a system in place to gather feedback from patients in the form of a feedback questionnaire. Feedback was collected from patients on an on-going basis. External patient surveys conducted by CARE Fertility London indicated high levels of satisfaction amongst patients.

Continuous improvement and innovation

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

  • The provider attended national and international conferences to keep updated with new developments in the field.
  • The provider was a senior lecturer and academic in the field of reproductive medicine.