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Inspection Summary


Overall summary & rating

Updated 20 December 2017

We carried out an announced comprehensive inspection on 8 November 2017 at The Leger Clinic to ask the service the following key questions; are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

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 clinic was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of the services it provides.

The Ledger Clinic offers services to NHS and private patients and is situated on the first floor of the medical centre with a lift offering access to people with mobility issues. The clinic offers assessment and treatment for males and females suffering from a wide variety of sexual problems. The clinic does not see people under the age of 18. 

The provider, which is The Leger Clinic Limited, is registered with the Care Quality Commission to provide services at The Leger Clinic, St Vincent Medical Centre, 77 Thorne Road, Doncaster, DN1 2ET. The clinic is based just outside of Doncaster town centre within St Vincent Medical Centre and the rooms used consist of a shared reception area on the ground floor and a shared waiting room and a consulting room on the first floor. There is free on-road parking on all surrounding streets.

The clinic holds a list of registered patients who are either referred to the service or contact the provider directly to register as a private patient.  The clinic is available to patients who reside in Doncaster and surrounding areas and also to patients who live in other areas of England who require the services.

As part of our inspection we reviewed 46 Care Quality Commission comment cards where patients and members of the public shared their views and experiences of the service. All of the 46 comment cards we received were extremely positive about the service experienced. Patients said the clinic offered an excellent service and staff were sensitive, professional, very caring and treated them with dignity and respect. Comments also told us that the environment was safe, clean and hygienic. Patients told us they received information to help them make informed decisions about their care and treatment. A theme identified, in the cards and with patients we spoke with, was that the clinic had significantly improved the lives of some of the patients.

The clinic is owned by a GP with a specialist interest in sexual dysfunction and administrative duties are performed by GP practice staff co-located in the same building. The GP was also a partner in the GP practice co-located in the same building. The GP was supported by members of administrative staff.  Patients could also be seen by a Psychosexual Therapist who worked with the service. 

The clinic opening hours are:

  • Monday 8.30am to 11.30am
  • Tuesday 8.30am to 12 noon
  • Wednesday 9am to 6pm
  • One Saturday per month from 8.15am to 3pm

The provider is not required to offer an out of hours service. Patients who need emergency medical assistance out of the clinic opening hours are requested to seek assistance from alternative services such as their own GP, the NHS 111 telephone service or accident and emergency.

Our key findings were:

  • There was a system in place for reporting and recording significant events.
  • Information about services and how to complain was available and easy to understand. 
  • Risks to patients were always assessed and well managed.
  • The clinic held a comprehensive central register of policies and procedures which were in place to govern activity.
  • The GP assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The GP had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The clinic had good facilities and was well equipped to treat patients and meet their needs.
  • The clinic proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour. 

The areas where the provider should make improvement are:

  • Review the security of the clinic's website online enquiry system.
Inspection areas

Safe

Updated 20 December 2017

We found that this service was providing safe care in accordance with the relevant regulations.

  • The clinic had clearly defined and embedded systems, processes and clinics in place to keep patients safe and safeguarded from abuse.
  • There were effective recruitment processes in place and all members of staff had received a Disclosure and Barring Service check (DBS check). (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 support staff who acted as a chaperone were trained to carry out this role and had a DBS check in place.
  • The clinic issued prescriptions and dispensed medicines to private patients. There was evidence of comprehensive training for clinicians undertaking this role and a policy and protocol in place for the dispensing of medicines. Systems and processes for repeat prescribing, including high risk medicines, kept patients safe.
  • There were various risk assessments in place which included a risk assessment for the control of Legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The clinic held evidence of Hepatitis B status and other immunisation records for clinical staff members.

Effective

Updated 20 December 2017

We found that this service was providing effective care in accordance with the relevant regulations.

  • The GP had the skills, knowledge and experience to deliver effective care and treatment.
  • The GP and support staff were suitably trained to carry out their roles. 
  • The clinic ensured sharing of information with NHS GP services when necessary and with the consent of the patient. For example, the clinic sent information of consultations to the patients regular GP.
  • The clinic had evidence of quality improvement through clinical audits that were relevant to their population. 

Caring

Updated 20 December 2017

We found that this service was providing caring services in accordance with the relevant regulations.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • There was evidence of the caring nature of staff. For example, patients shared with us how the GP put them instantly at ease during consultations.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Updated 20 December 2017

We found that this service was providing responsive care in accordance with the relevant regulations.

  • Patients said they did not wait for long to be seen after they were referred to the clinic and that was continuity of care. 
  • The clinic had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand. No complaints had been made, however the GP proactively gained feedback from patients, including verbal feedback.
  • Translation services were available for patients whose first language was not English. 

Well-led

Updated 20 December 2017

We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had a clear vision to deliver high quality care and promote good outcomes for patients. 
  • There was a clear leadership structure and support staff felt supported by the GP. The clinic had a number of policies and procedures to govern activity.
  • There was an overarching governance framework which supported the delivery of good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The clinic encouraged a culture of openness and honesty.
  • The clinic proactively sought feedback from staff and patients which it acted on.
  • There was a focus on continuous learning and improvement at all levels.