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Inspection carried out on 23 January 2019

During an inspection looking at part of the service

We carried out an announced follow-up comprehensive inspection on 23 January 2019 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 practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

CQC inspected the service previously on 16 February 2018 and asked the provider to make improvements regarding regulations 12 safe care and treatment and regulation 13 safeguarding. This was because emergency medicines were not available in keeping with best practice guidance; there were insufficient steps taken to liaise with the patients NHS GP; suitable background checks had not been conducted for staff and the provider did not take sufficient steps to ensure adults accompanying children had parental responsibilities.

We checked these areas as part of this comprehensive inspection and found these had been resolved.

At Ultima Vitality the aesthetic cosmetic treatments that are also provided are exempt by law from CQC regulation. Therefore, we were only able to inspect the treatment for the GP services and not the aesthetic cosmetic services.

The provider 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.

Feedback from patients was positive about accessibility and the flexibility of the service.

Our key findings were:

  • Patients were treated in line with best practice guidance and appropriate medical records were maintained.
  • The environment was clean, a cleaning schedule was in place and this was monitored.
  • An induction programme was in place for staff and staff had access to all policies and procedures.
  • Information about services and how to make a complaint was available in the clinical and on the website however, this information did not include the next steps the patient should take if they were dissatisfied with the outcome of an investigation.
  • Systems were in place to protect personal information about patients. The company and GP were registered with the Information Commissioner’s Office.
  • The service had clear systems to keep people safe and safeguarded from abuse and protect children from harm. This information had been updated and improved since the last inspection.
  • Governance systems and processes were in place; however, the provider did not complete clinical audits.
  • The provider followed the policies and procedures in place.
  • The service encouraged patients to feedback through the website, however, they did not seek direct feedback for example through a comment box, patient survey or questionnaire.
  • The provider did not maximise the dignity and privacy of patients because a privacy screen was not available in the consultation room.

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

  • Review patient feedback processes.
  • Review how privacy and dignity is preserved for patients who need to undress during their consultations.
  • Prioritise the introduction of audits as a part of reviewing the effectiveness of the service, for example, clinical outcomes, seeking consent and completeness of records.
  • Update the complaints policy to include information about independent organisations who would review the outcome of a complaints investigation carried out by the service.
  • Introduce a process to ensure clinical skills are refreshed and updated.
  • Take steps to provide an appropriate sink in the consulting room.
  • Formalise the business continuity plan.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 16 February 2018

During a routine inspection

We carried out an announced comprehensive inspection on 16 February 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 some areas 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.

Ultima Vitality is a private GP practice and cosmetic clinic run by Mesopotamia Surgical Ultima Vitality Limited. It is based in Didsbury a suburb of Manchester. The practice has been at its current site since 2014.

At Ultima Vitality the aesthetic cosmetic treatments that are also provided are exempt by law from CQC regulation. Therefore we were only able to inspect the treatment for the GP services and not the aesthetic cosmetic services. The GP 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:

  • Patients were treated in line with best practice guidance and appropriate medical records were maintained.
  • An induction programme was in place for staff and staff had access to all policies and procedures.
  • Information about services and how to complain was available.
  • The service encouraged feedback from both patients and staff.
  • Systems were in place to protect personal information about patients. The company and GP were registered with the Information Commissioner’s Office.
  • The service had clear systems to keep people safe and safeguarded from abuse; however this information needed to be updated.
  • The service had a programme of ongoing quality improvement activity.
  • Governance systems and processes were in place.
  • There were gaps in how well the service followed their policies and procedures for example, the recruitment and information sharing policies.
  • Some policies and systems needed to be further developed and updated to ensure the best outcome for patients was promoted for example, the chaperone and adults safeguarding and child protection policies.

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

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure patients are protected from abuse and improper treatment.

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 processes and procedures for infection prevention and control.
  • Review systems for communication with other health professionals involved in the patient’s care.
  • Review induction and the training matrix.
  • Review a system to review policies and procedures periodically.
  • Review how employment records required under Schedule 3 of the Act are archived.
  • Review systems for monitoring the outcomes for patients who receive clinical treatment.