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Inspection Summary


Overall summary & rating

Updated 15 June 2018

We carried out an announced comprehensive inspection on 9 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 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 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. We also planned the inspection to check on concerns raised which we had received.

The GP Surgery Ltd provides private medical and aesthetic services at The GP Surgery Wimbledon in the London Borough of Merton. Services are provided to both adults and children.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of the provision of advice or treatment by a medical practitioner, including the prescribing of medicines. At The GP Surgery Ltd some aesthetic treatments that are provided by doctors are exempt from CQC regulation.

We received feedback from 25 people about the service, including comment cards, all of which were very positive about the service and indicated that patients were treated with kindness and respect. Staff were described as helpful, caring, thorough and professional.

Our key findings were:

  • There were arrangements in place to keep patients safe and safeguarded from abuse.
  • Health and safety and premises risks were not always assessed and well-managed.
  • There were safe systems for the management of medicines
  • Staff knew how to deal with medical emergencies. Appropriate medicines and equipment were available.
  • The premises were clean and hygienic.
  • The service had safe systems for recording, acting on and improving when things went wrong.
  • Assessments and treatments were carried out in line with relevant and current evidence based guidance and standards.
  • There was evidence of some quality improvement measures.
  • The systems for monitoring training for staff were not always effective.
  • Staff treated patients with kindness, respect, dignity and professionalism.
  • Opening hours reflected the needs of the population and patients were able to book appointments when they needed them.
  • The service had a clear procedure for managing complaints. They took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
  • Leaders had the skills and capacity to deliver the service and provide high quality care.
  • Staff stated they felt respected, supported and valued. They were proud to work in the service.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • The service asked staff and patients for feedback about the services they provided.

There were areas where the provider could make improvements and should:

  • Review the management of health and safety of the premises including legionella testing and fire safety.
  • Ensure that staff receive training in safeguarding adults, infection control, fire safety and information governance appropriate to their roles.
  • Review the systems to ensure adequate and ongoing monitoring of staff training according to the staff training policy.
  • Review the use of clinical audit to improve quality.
  • Review the systems for verifying the identity of adults accompanying child patients.
Inspection areas

Safe

Updated 15 June 2018

We found that this service was providing safe care in accordance with the relevant regulations.

  • The service had policies and procedures in place to keep people safe and safeguard them from abuse.
  • Staff were qualified for their roles and the provider completed essential recruitment checks.
  • Some systems were in place to ensure infection control was managed appropriately.
  • Health and safety and premises risks were not always assessed and well-managed.
  • The service had suitable arrangements for dealing with medical emergencies.
  • The management of medicines including prescribing was safe.
  • The service had safe systems for recording, acting on and improving when things went wrong.
  • A system for acting on medicines and safety alerts was implemented after the inspection.
  • The service did not have effective procedures for sharing information with a patient’s GP or verifying a patient’s identity, however these were put in place immediately following the inspection.

Effective

Updated 15 June 2018

We found that this service was providing effective care in accordance with the relevant regulations.

  • Assessments and treatments were carried out in line with relevant and current evidence based guidance and standards.
  • We found evidence of quality improvement measures including records audits, however there was minimal evidence of clinical audit.
  • The service obtained consent to care and treatment in line with legislation and guidance.
  • The service had clear arrangements when patients needed to be referred to other health care professionals or specialist services.
  • There was evidence of a comprehensive induction programme and structured appraisals for staff.
  • There was evidence that some staff to had not completed some safety training relevant to their roles, however the provider implemented a training policy after the inspection.

Caring

Updated 15 June 2018

We found that this service was providing caring services in accordance with the relevant regulations.

  • We received feedback from 25 patients including Care Quality Commission comment cards. Patients were positive about all aspects of the service the service provided.
  • Patients reported staff were kind, caring and supportive. They said that they were given helpful, honest explanations and information about medical treatment and said their doctors listened to them.
  • We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

Responsive

Updated 15 June 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

  • The facilities and premises were appropriate for the services delivered.
  • Services offered met the needs of a range of population groups.
  • The service’s appointment system was efficient and met patients’ needs. Patients could get an urgent appointment the same day.
  • The service took patients views seriously. They responded to concerns and complaints quickly and constructively to improve the quality of care.

Well-led

Updated 15 June 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

  • There was an organisational structure and staff were aware of their roles and responsibilities.
  • The service had arrangements to ensure the smooth running of the service.
  • Regular staff meetings were held and there was evidence of clear communications with all staff.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • There was evidence of processes for managing issues and performance but some risks were not managed effectively.
  • There was evidence of some quality improvement measures.
  • The service encouraged feedback from patients and staff and this was used to monitor performance.