5 December 2018
During a routine inspection
Verulam Clinic is operated by Verulam Clinic Limited. The service provides diagnostic pregnancy and fertility imaging services (ultrasound scans) to self-funded women in St Albans and the surrounding areas.
The service also offers additional services, which are not included in their regulated activity. This includes complementary health treatments and small group classes to couples, mothers, and babies.
We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 5 December 2018.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
Services we rate
We have not previously rated this service. At this inspection in December 2018, we rated the service as good overall.
We found areas of good practice:
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Staff were caring, kind and engaged well with women and their families.
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Services were planned in a way that met the needs of women and the local community. Women were offered a choice of appointments.
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Managers promoted a positive culture that supported and valued staff. Staff confirmed they felt respected and valued.
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The service used current evidence-based guidance and good practice standards to inform the delivery of care and treatment. Staff demonstrated a good understanding of the national legislation that affected their practice.
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Verulam Clinic had a clear vision and strategy for what they wanted to achieve, with quality and sustainability as the top priorities.
However, we found the following areas of practice that the service needed to improve:
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Staff did not receive mandatory training in key skills after their initial induction to the service. There was no oversight on what training the sonographers had completed at their substantive employer.
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While staff understood the need to protect people from abuse, they had not all completed safeguarding training at the required level to ensure they had the appropriate knowledge to do so. However, this was rectified after our inspection.
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Verulam Clinic did not have full oversight of the competencies, skills and capabilities of staff working for their service. There was no formal staff appraisal system in place at the time of our inspection. However, this was rectified after our inspection.
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We were not assured that the service always kept up-to-date with important national and statutory legislation.
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Informed consent was not appropriately gained from women who did not have English as their first language. However, this was rectified after our inspection.
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While the service generally had effective arrangements in place for identifying and recording risks, there was little evidence that these risks and their mitigating actions were discussed with the wider team.
Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected Verulam Clinic. Details are at the end of the report.