This service is rated as
Good
overall. (Previous inspection June 2018 – unrated).
The key questions are rated as:
Are services safe? – Requires improvement
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 Bond Street as part of our inspection programme to rate all providers of independent health services.
The service provides comprehensive travel health services in addition to other services which are out of scope of CQC regulation including covid 19 testing and occupational health services.
Frances Rea is currently the CQC registered manager. However, we have received an application to cancellation Frances Rea’s registration as registered manager and have been informed that Jason Gibbs (Head of Medical services) is in the process of applying to be the registered manager of this location. 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.
Our key findings were:
- The provider had systems and processes in place to address most risks; including those related to recruitment of staff and safeguarding. However, there was a lack of oversight or action to address risks including fire risks. We also saw that here were minor infection control risks and a faulty sink in one of the clinic rooms.
- Medicines were managed appropriately although we found that labelling for dispensed medicines did not comply with current guidance.
- There was appropriate emergency equipment on site and the service had risk assessed the absence of a defibrillator and had arrangements in place to access one located short walk from the clinic. .
- There were systems for managing significant events and responding to patient safety alerts.
- Clinical care was delivered in line with travel health guidelines. The provider had initiated an audit of the clinic and had reviewed the consultations of staff who worked there.
- All staff had received appropriate training. GDPR training completed by staff included information governance, however this was not documented in staff records we looked at.
- The provider had newly established systems in place to gather feedback from patients, including complaints. Feedback we reviewed on external websites was largely positive.
- There was a strong focus on staff wellbeing and staff had the opportunity to feed into organisational decision making.
- There was a clear vision and set of business plans to aid the organisation in achieving its goals.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Consider documented information governance training.
- Consider replacement of the faulty foot pump sink in one of the consulting rooms.
- Continue with plans to undertake a programme of clinical audit.
- Utilise the new client survey to gather feedback from service users and use this to improve services.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care