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Archived: Bromsgrove Private Clinic Requires improvement


Inspection carried out on 11 and 13 December 2018

During a routine inspection

Bromsgrove Private Clinic is operated by Elite Health Services Limited. The service had one registered location. The service provides ultrasound scans, X-rays and MRI (Magnetic Resonance Imaging) diagnostic facilities for adults and children. We inspected diagnostic imaging services at this location.

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.

We inspected this service using our comprehensive inspection methodology. We carried out a short notice announced inspection on 11 December 2018 and an unannounced inspection on 13 December 2018. This was the first inspection since registration. Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The service provided was diagnostic and screening procedures and treatment of disease, disorder or injury.

Services we rate

We previously did not have the authority to rate this service as legislation had not applied to all types of independent services, which meant that some providers had been inspected, but not rated. The Department of Health had amended the performance assessment regulations to enable CQC rate almost all independent healthcare providers. We rated this service as inadequate overall.

We found areas of practice that the service needed to improve:

  • The service had no incident reporting system in place. Clinical incidents were not always recorded correctly.

  • The service did not always have reliable systems in place to protect patients and staff from the risks of radiation exposure. At the time of the inspection, radiation protection signs could not be illuminated which meant people could not easily identify if an x-ray procedure was in progress. This was rectified after the inspection.

  • Routine quality assurance and servicing was not in place at the time of inspection to ensure that the x-ray and MRI equipment was safe for use. We were provided with risk assessments of the equipment which had been updated following the inspection. Clinical staff received training following our inspection to enable them undertake quality assurance.

  • The service did not have radiation risk assessments available at the time of the inspection and this did not comply with IRR regulation 2017. They updated and provided risk assessments following the inspection.

  • The service did not have enough emergency equipment to keep patients safe in the event of an emergency. We raised this with senior staff who ordered more equipment to keep both children and adults safe.

  • Hand hygiene audits were not undertaken to measure staff compliance with the World Health Organisation’s (WHO) ‘Five Moments for Hand Hygiene.’

  • Staff had the appropriate qualifications for their role within the service; however, we could not be assured that the radiographers had up-to-date competencies for their role.

  • At the time of inspection, there was lack of robust governance process in place to provide oversight around risk assessments, equipment quality assurance and diagnostic reference levels (DRLs) as required under IR(ME)R. Following inspection, the service commenced analysis and monitoring of DRLs and equipment quality assurance and subsequently provided evidence of this.

  • The governance system in relation to the management of risk did not operate effectively to ensure that leaders have clear oversight of the risk of harm to patients and their relatives.

However, we found the following areas of good practice:

  • There was a programme of mandatory training in key safety areas, which all staff completed, and systems for checking staff competencies.

  • Staff understood what to do if a safeguarding issue was identified.

  • Records seen were up-to-date, complete and kept protected from unauthorised access.

  • Staff demonstrated a kind and caring approach to their patients, supported their emotional needs and provided reassurance.

  • Appointments were scheduled to meet the needs and demands of the patients who required their services.

  • The service had systems in place to acquire feedback from patients to enable them to continually improve the service being provided.

  • All of the patient feedback we received reflected a good standard of kind, compassionate and understanding care.

Following this inspection, we sent a letter raising our concerns. In response to our letter, the provider decided to pause all regulated activity until 8 January 2019. The provider took actions to address the concerns we raised in the letter.

We told the provider that it must take some actions to comply with the regulations and that it should make other improvements. We also issued the provider with two requirement notices that affected diagnostic and screening procedures and treatment of disease, disorder or injury. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central)