04 February 2019
During an inspection looking at part of the service
We carried out an announced comprehensive inspection at CP Medical Clinic on 11 December 2018 to follow up the concerns identified at our previous inspection in June 2018. You can find the reports of our previous inspections by selecting the ‘all reports’ link on our website.
This inspection was an announced focused inspection carried out on 4 February 2019 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified at our previous inspection on 11 December 2018.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements and improvements made since our last inspection.
CP Medical Clinic provides private medical services at 61-63 Sloane Avenue in the Royal Borough of Kensington and Chelsea and treats adults and children. The provider, Dr David O’Connell is registered with CQC under the Health and Social Care Act 2008 to provide the regulated activity of Treatment of disease, disorder and injury at this location.
At this inspection we found action had been taken on most of the issues identified at the previous inspections.
Our findings were:
Are services safe?
We found that this service was providing safe care in accordance with the relevant regulations.
Are services well-led?
We found that this service was not providing well-led care in accordance with the relevant regulations.
Our key findings were:
- The service had succeeded in making improvements to most aspects of policy and protocol, but there were areas for improvement identified. The provider was not consistently following policies and procedures used by staff at the host clinic.
- The service had reviewed risks associated with the service’s premises and ensured formal safety risk assessments were carried out at regular intervals to reduce risks to patients and staff.
- Management of fire risk kept people safe. The service had maintained a record of fire drills as outlined in the fire risk assessment.
- The provider monitored people on high-risk medicines. Records we looked at showed patients’ health was monitored in relation to the use of medicines and followed up on appropriately.
- The provider had started to implement a system to ensure the safe management of prescribing of controlled drugs.
- Records were not always written and managed in a way to keep people safe. Patient notes were not easily accessible in an emergency and it was not possible for the provider to share information with other services when there was an urgent need.
- CCTV cameras in the two consulting rooms had been removed. The provider did not have signs up warning people about CCTV recording in the host clinic. Staff put up signs during our inspection.
- There was no employee record for one member of staff who was employed by the provider in the carrying on of regulated activities and no record of a DBS check. During our inspection, the provider was able to obtain evidence of DBS disclosure application for the employee.
- Governance arrangements had improved to ensure effective oversight of risk. There was a controlled drugs policy in place and leaders had completed priority actions from the fire safety risk assessment.
We identified regulations that were not being met and the provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
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 ease of access to patient notes kept by the provider.
- Continue to develop quality improvement systems that monitor the positive impact on quality of care and patient outcomes.
- Review the systems for checking expiry dates on medicines stored by the provider.
- Review the process for sourcing patient feedback to improve and develop the service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care