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The London Circumcision Clinic Good

We are carrying out a review of quality at The London Circumcision Clinic. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Good

Updated 23 July 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at The London Circumcision Clinic as part of our inspection programme.

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.

The London Circumcision Clinic is an independent health service based in East London, where circumcisions are provided.

Our key findings were:

  • Systems and processes kept patients safe and safeguarded from abuse.
  • There was evidence the service carried out care and treatment in line with relevant guidance.
  • There was a system for the doctor to keep up-to-date with new guidance and patient safety alerts.
  • The service had systems to update external bodies such as GPs and consultants of care and treatment being provided to their patients.
  • Systems were in place to protect personal information about patients.
  • The doctor understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005.
  • Annual risk assessments were carried out including in relation to health and safety.
  • There were appropriate systems to obtain parental responsibility and seek consent for procedures carried out on children.

The areas where the provider should make improvements are:

  • Continue to work on their quality improvement programme.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 23 July 2019

We rated safe as

Good because:

Safety systems and processes

The service

had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments including fire safety risk assessments. It had appropriate safety policies, which were communicated to staff. 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 extensive systems in place to assure that an adult accompanying a child had parental authority, both parents had to be present for the procedure and both had to give written consent.

  • 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. We were told they knew how to identify and report concerns.

  • There was an effective system to manage infection prevention and control, this included legionella testing.

  • 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

  • We were told staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. We saw evidence of completed training such as basic life support including the use of the defibrillator and fire awareness training that supported this.

  • The service had acquired a new building which it planned to move into by the end of 2019, we saw that the service had begun carrying out risk assessments on this and looking at how this could impact on safety.

  • There were appropriate indemnity arrangements in place for the doctor, 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 hand 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 Department of Health and Social Care (DHSC) guidance in the event that they cease trading.

  • The doctor made appropriate and timely referrals when necessary in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including anaesthesia, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.

  • The service kept appropriate records of the one medicine (Augmentin) that they prescribed. They were currently carrying out an audit into the prescribing of this medicine, looking at whether any post-operative infections would occur if this antibiotic was not routinely prescribed post procedure.

  • There were effective protocols for verifying the identity of children. The practice policy stated that the childs’ birth certificate needed to seen alongside photographic identification of both parents, both of whom needed to give written consent for the procedure and be present on the premises when the procedure was taking place.

Track record on safety and incidents

The service

had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues, this is included fire risk and infection prevention and control.

  • The service monitored and reviewed each procedure. 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 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. The doctor told us he would support them when they did so.

  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and identified themes and took action to improve safety in the service. For example, in the last 12 months there had been two post-operative bleeds, the service reviewed these as a significant event and concluded that there was nothing that could have been done to prevent them, but highlighted the importance of clarity in post-operative care and procedures to contact the service for any post-operative issues.

  • 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 told us they would give affected people reasonable support, truthful information and a verbal and written apology.

  • The service had a system to learn from external safety events as well as patient and medicine safety alerts. However, none had been received which were relevant to the service.

Effective

Good

Updated 23 July 2019

We rated effective as

Good

because:

Effective needs assessment, care and treatment

The provider had systems to keep up to date with current evidence based practice. We saw evidence that the doctor assessed needs and delivered care and treatment in line with current legislation, standards and guidance relevant to their service.

  • The doctor attended peer review meetings with other doctors who carried out circumcisions every three to six months, where complex cases and learning was shared.

  • Patients’ immediate and ongoing needs were fully assessed.

  • We saw no evidence of discrimination when making care and treatment decisions.

  • Staff assessed and managed patients’ pain where appropriate.

  • The doctor reminded patients of the remit of the service and where to seek further help and support if required.

Monitoring care and treatment

The service was involved in quality improvement activity.

  • Once a year the service had a clinical director and consultant in emergency medicines attend the premises to observe the procedures taking place and the premises, review the doctors’ documentation. We viewed the report left by the consultant which stated that the procedures carried out appropriately followed guidelines and there was adequate documentation.

  • The service had begun an audit which looked at 197 cases over a three month period who had been prescribed antibiotics post procedure and did not end up with an infection. A second cycle of the audit was in process, which looked at a further three months of cases where antibiotics were not routinely prescribed post operation to see whether there was an adverse impact of not automatically prescribing antibiotics post procedure.

  • The service used information about care and treatment to make improvements. A record was kept of all reported complications to review to see whether changes to procedures could be made.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • The doctor was appropriately qualified.

  • The provider had an induction programme for all newly appointed staff.

  • The doctor was registered with the General Medical Council (GMC) and was up to date with revalidation.

  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • We saw evidence that showed that all appropriate organisations including GPs and consultants (for second opinions) were kept informed and consulted where necessary.

  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP when sharing was deemed necessary.

  • The provider had risk assessed the treatments they offered, and patients aged over three years were given a follow up appointment the week after their procedure as a safety measure as this age group was most likely to have complications.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision when required.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 23 July 2019

We rated caring as

Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from CQC patient comment cards was positive about the way staff treat people

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.

  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.

  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private area to discuss their needs.

  • The service told us they mitigated the requirements for chaperones as parents were always present during a circumcision of a child and a clinical assistant was always present during the circumcision of an adult.

Responsive

Good

Updated 23 July 2019

We rated responsive as

Good

because:

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. The service carried out their own patient survey and had 23 responses, the survey reflected the questions from the national GP patients survey and patients were 100% positive about the service, including feeling that their privacy and dignity was respected, feeling involved in decisions made about their care and being given timely information about care and treatment.

  • The facilities and premises were appropriate for the services delivered.

  • Patients could access information about the service through a variety of sources including a website and leaflets.

  • Treatments were personalised to reflect individual patients’ needs. Post-operative information sheets were given to all patients.

Timely access to the service

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

  • The service was open on a Sunday and provided appointments from 9:30am when it opened with no specified end time as this was based on demand. When demand for appointments were high the service carried out additional week day appointments. The service had a mobile telephone, which was manned seven days a week from 10am to 8pm for appointment bookings, queries and concerns.

  • Waiting times, delays and cancellations were minimal and managed appropriately.

Listening and learning from concerns and complaints

  • The service had complaint policy and procedures in place, which detailed who to contact to take their complaint further if they were not happy with the response from the service.

  • Information about how to make a complaint or raise concerns was available.

  • The service told us they had not received any complaints in the last two years but had systems and processes for acknowledging and dealing with these if the need arose.

Well-led

Good

Updated 23 July 2019

We rated well-led as

Good because:

Leadership capacity and capability;

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

  • The doctor was knowledgeable about issues and priorities relating to the quality and future of services. He understood the challenges and were addressing them, this included putting systems in place to move to a new premises.

Vision and strategy

The service had a vision and 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 monitored progress against delivery of the strategy, which included securing a new building to relocate to and providing additional treatments to patients.

Culture

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

  • The service focused on the needs of patients.

  • The doctor told us he would act on behaviour and performance inconsistent with the vision and values.

  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • There were processes for providing all staff with the development they need. This included appraisals.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out.

  • Staff had clear roles and accountabilities.

  • The doctor had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of the doctor could be demonstrated through audit of their procedures and consultation documentation carried out by a clinical director and consultant in emergency medicine. The doctor had oversight of safety alerts and incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • The information used to monitor performance and the delivery of quality care was accurate and useful.

  • Performance information was not combined with the views of patients.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

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 provided patients with satisfaction questionnaires, the results of which had not been analysed to see if there were improvements to the service that could be made.

Continuous improvement and innovation

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

  • The service made use of external reviews and peer review and used this to make improvements. For example the service was leading on a system to ensure there was no bias when dealing with patient complaints by enabling external review and management where necessary from one of their external peers.