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Archived: Private GP Clinic Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 30 August 2019

Inspection areas


Requires improvement

Updated 30 August 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 including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • 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. Legionella risk assessments and water monitoring were carried out by the landlord. The service held copies of the water testing results but were not aware of concerns raised about low levels of legionella identified in the building’s cold water system by the water testing in May 2019. Legionella is a term for particular bacteria which can contaminate water systems in buildings. Since the inspection we have seen evidence that the cold-water system supplying the building has been changed to reduce the risk of legionella reoccurring in the cold-water system.
  • The provider ensured that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

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.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. Staff knew how to identify and manage patients with severe infections, for example sepsis. There were flowcharts in reception and in every clinical room advising staff how to treat medical emergencies.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.
  • All electrical equipment was checked to ensure that equipment was safe to use and clinical equipment was checked to ensure it was working properly.
  • Emergency medicines and equipment were easily accessible to staff in a secure area of the clinic and all staff knew of their location. The clinic had suitable emergency resuscitation equipment including an automatic external defibrillator (AED) and oxygen. The clinic also had medicines for use in an emergency. Records completed showed regular checks were done to ensure the equipment and emergency medicines were safe to use.
  • The landlord completed annual evacuation fire drills and weekly fire alarm testing. Emergency policy and procedure and evacuation procedures were discussed at staff meetings. Since the inspection the provider has provided a record of which staff had participated in evacuation fire drills in the last three years, which showed some staff had been involved in all three evacuation fire drills however some staff, including both GPs, had only been involved in one evacuation fire drill in the last three years.
  • Staff had received annual health, safety and fire training.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff did not always have 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 recorded in individual care records.
  • We noted that information was not always available to relevant staff in an accessible way, for example should a medicines alert or recall be issued a manual search of individual records would need to be carried out.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had not considered a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading. Since the inspection the provider has provided evidence that they have reviewed and updated their business continuity plan to include how patient medical records will be handled in the event the business ceases to trade. 
  • 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. However, they were not completing regular medicines audits.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks.
  • The service had not carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.

Track record on safety and incidents

The service had a good safety record.

  • There were 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.

Lessons learned and improvements made

The service did not always learn and make 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 acted on and learned from some external safety events. The service did not have an effective mechanism in place to ensure all alerts had been acted on. We saw evidence that the provider had acted on some patient safety alerts that were not related to medicines. For example, in 2016 the practice took action to ensure their defibrillator was not affected by a field service update relating to possible issue with the batteries used in certain makes of defibrillators. We also saw that staff had been made aware of concerns regarding the quality of a particular test carried out by a private pathology laboratory. There was no record of alerts that the service had determined did not require action. The provider did not demonstrate where they had assessed, discussed or taken action on medicines related alerts or safety updates such as valproate (a medicine prescribed for the treatment of epilepsy or bipolar disorder). The GP we spoke with was aware of medicines alerts. Since the inspection the providers has introduced a new system for recording safety alerts but this still did not contain references to drug safety updates or drug alerts that were potentially relevant to the service and had been published since the system had been introduced.


Requires improvement

Updated 30 August 2019



Updated 30 August 2019



Updated 30 August 2019

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, the practice offered evening appointments two evenings a week and ad hoc Saturday clinics. The service had also introduced the menopause clinic.
  • The facilities and premises were appropriate for the services delivered.
  • Appointments were offered with male and female GPs.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

Patients were able access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had a complaint policy and procedures in place. The service had received three complaints in the last 12 months. The service learned lessons from individual concerns and complaints. It acted as a result to improve the quality of care.


Requires improvement

Updated 30 August 2019

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • 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.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including the nurse and health care assistant, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability but these did not always support good governance and management.

  • Structures, processes and systems to support good governance and management were not always clearly set out, understood and effective.
  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety however we found they had not always assured themselves that they were operating as intended.

Managing risks, issues and performance

There was a lack of clarity around processes for managing risks, issues and performance.

  • There was a process to identify, monitor and address current risks including risks to patient safety. However, the service did not assure itself that mitigating actions identified by the landlord’s risk assessments and water testing had been completed. The service was not aware of any action carried out by the landlord to resolve this but on the day of inspection the service contacted the landlord who confirmed verbally that action had been taken. The service had not seen evidence of water testing results since the water analysis carried out in May 2019 which reported concerns.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight incidents, and complaints.
  • Leaders did not have oversight of all safety alerts, decision making about whether safety alerts required action was not clearly recorded and there was no record of action taken for medicines alerts. Staff told us that the clinical system could not be searched for specific medicines, so no action was taken for medicines alerts. The GP we spoke with told us that they were aware of the alerts and would take action if they knew of any patients prescribed that particular medicine, but this was not discussed with other clinical staff or documented. Since the inspection the provider has introduced a new system for recording alerts but this still did not contain references to drug safety updates or drug alerts that were potentially relevant to the service and had been published since the system had been introduced.
  • Clinical audit was not used routinely to monitor prescribing or to drive clinical improvement.
  • The provider had plans in place and had trained staff for major incidents.
  • The provider did not demonstrate that they had reviewed minor surgery outcomes.

Appropriate and accurate information

The service did not have appropriate and accurate information.

  • Operational information was not always used to ensure and improve performance. For example, an audit of blood test results being put onto the system and comments added by GPs however following the discussion of the initial results the second cycle showed no improvement.
  • The service did not monitor prescribing, did not take action on medicines alerts and did not carry out regular or comprehensive clinical audits. The service told us this was because they were not able to search their clinical system for specific medicines. The service has tried twice since 2018 to upgrade their clinical system but encountered serious problems on both occasions and has no immediate plans to upgrade to a new system.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. The service had not given consideration to a system to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading. Since the inspection the service have provided evidence that they have reviewed and updated their business continuity plan to include how patient medical records will be handled in the event the business ceases to trade.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback. There was a suggestion box in reception and patients were encouraged to provide feedback through online feedback sites. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • The clinicians within the service were encouraged to research new ideas and one GP was working alongside a mentor from the British Menopause Society to deliver a menopause service which offered body identical (bioidentical) hormone replacement therapy as well as compound and conventional hormone replacement therapy.
  • The service had researched available treatments to treat urinary incontinence in women and introduced a new treatment for this condition. The service was working closely with consultants from local hospitals with the intention of making this treatment more widely available. 
  • Staff were encouraged and supported in their personal development.
  • The service offered a microsuction service to NHS patients through referral from their GP. The lead GP for this service had delivered microsuction training to other organisations, both NHS and private.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • The service did not demonstrate how quality was monitored or improved in the service.