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Inspection Summary

Overall summary & rating

Updated 26 March 2019

We undertook a comprehensive inspection of 27 Wimpole Street on the 28 March 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found that the service was providing effective, caring, responsive, well led care however, they were not providing safe care in accordance with the relevant regulations.

The full comprehensive report following the inspection on 28 March 2018 can be found by

selecting the ‘all reports’ link for 27 Wimpole Street on our website at

We undertook an announced focused inspection of 27 Wimpole Street on the 22 February 2019 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 March 2018, these were;

  • There was no health and safety policy.
  • Actions from a fire risk assessment had not been completed.
  • There was no risk assessment to determine which staff needed infection control training.

This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Our findings were:

Are services safe?

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

27 Wimpole Street is a private doctor consultation and treatment service. The service offers private consultations with a general physician and a gynaecologist. There are two GPs, one male, one female, a part time nurse and two administrative staff. The service operates five days a week from 27 Wimpole Street, London. The building is owned by the service, however services are only provided on the ground floor. They only provided services for adults.

Dr KJ Ugboma 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.

This service is registered with CQC under the Health and Social Care Act 2008 for the regulated activities of Treatment of disease, disorder or injury and Diagnostic and screening procedures.

We received 33 completed CQC comment cards which were all very positive about the level of service and the care provided, patients felt that they were treated with dignity and respect.

Our key findings were:

  • Although we could see that some of the actions from the 2019 fire risk assessment had been completed, the practice could not evidence all actions had been completed.
  • The service lead was the lead member of staff for safeguarding and all clinical staff had undertaken adult and child safeguarding training, however non-clinical staff received their training from the safeguarding lead.
  • The service had established a health and safety policy and non-clinical staff members had undertaken infection control training.
  • The provider was aware of current evidence based guidance and they had the skills, knowledge and experience to carry out his role.
  • The provider was aware of their responsibility to respect people’s diversity and human rights.
  • Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
  • There was a complaints procedure in place and information on how to complain was readily available.
  • Governance arrangements were in place. There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • The service had systems and processes in place to ensure patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • There was a clear leadership structure and staff felt supported by management.
  • The service had systems in place to collect and analyse feedback from patients.

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

  • Review the need to establish a cold chain policy with appropriate recording of temperatures.
  • Review the 2016 fire risk assessment and ensure that all actions have been completed.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas


Updated 26 March 2019

Safety systems and processes

The service had clear 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, this included a health and safety and infection control policies.
  • Staff received safety information from the service as part of their induction and refresher training.
  • Arrangements for safeguarding reflected relevant legislation and the service had processes in place to access relevant information for patients’ local safeguarding teams where necessary. Policies were accessible to all staff and policies clearly outlined who to contact for further guidance if staff had concerns about a patient’s welfare. The service lead was the lead member of staff for safeguarding and had received training on safeguarding children and vulnerable adults relevant to their role. GPs were trained to child safeguarding level three, nurses were trained to level two, however none of the administration staff had received formal safeguarding training. Staff told us the GP would provide training to them and that they understood their responsibilities. Whilst the provider did not directly provide clinical services for patients under 18 there is an expectation that staff working in a health care setting are trained in child safeguarding in line with the intercollegiate guidance. This recommends child safeguarding training and competencies for not only those directly caring for children but also those providing care for their parents or carers.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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 adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control, which included a policy, risk assessment and training for staff.
  • 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.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for agency staff tailored to their role.
  • 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.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There had been a fire risk assessment in 2016 which had identified remedial action, the service had been unable to confirm that all of these actions had been taken, such as monthly checking of all fire doors and emergency lights and ensuring that there was adequate lightning protection. All fire equipment had been serviced and checked. Staff had received fire training and the service carried out fire drills, however whilst the service informed us that fire alarms were checked on a weekly basis this was not documented.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff 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 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.

Safe and appropriate use of medicines

The service had some reliable systems for appropriate and safe handling of medicines.

  • The provider did administer some travel vaccines. These were stored in a medical fridge with an external thermometer, the temperature was recorded daily but only once a day, Public Health England recommend that temperatures are taken twice daily to ensure that the temperature is maintained between +2 deg C and +8 deg C in order to monitor fridge failure. The service did not have a cold chain policy to govern this activity.

  • The provider received patient safety alerts from the Independent Doctors Federation (IDF), we saw examples of alerts being acted upon.

  • All prescriptions were issued on a private basis by the provider. Blank prescription pads were stored in a locked cupboard and were numbered.

  • The provider did not keep stock or prescribe any controlled drugs.

Track record on safety

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.
  • All staff had received annual basic life support training.
  • The service had developed a business continuity plan for events such as power failure or building damage.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety in the service.
  • 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.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology.
  • There was an incident reporting policy and there were procedures in place for the reporting of incidents and significant events. There had been no incidents or significant events reported in the last 18 months.
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.


Updated 26 March 2019


Updated 26 March 2019


Updated 26 March 2019


Updated 26 March 2019