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ToHealth Limited Also known as Waterloo Health Clinic

Inspection Summary


Overall summary & rating

Updated 4 July 2018

We carried out an announced comprehensive inspection on 30 April 2018 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.

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 service has a registered manager. 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.

This provider offers private GP services, and vaccinations.

Seven patients provided feedback about the service on the Care Quality Commission comments cards, all the comments were positive.

Our key findings were:

  • Policies and procedures were in place to support the delivery of safe care.
  • The provider had a clear vision to deliver high quality care for patients.
  • There were systems and processes in place for reporting and recording significant events and sharing lessons to make sure action could be taken to improve safety in the practice.
  • The service had clearly defined systems, processes and practices to minimise risks to patient safety however on the day of the inspection some of the process had not been fully put into place, after the inspection we were provided with evidence to show all processes were implemented.
  • The service had adequate arrangements to respond to emergencies.
  • Staff were aware of and used current evidence based guidance relevant to their area of expertise to provide effective care.
  • Staff had the skills and knowledge to deliver effective care and treatment.
  • There was an effective system in place for obtaining patients’ consent.
  • The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.
  • The clinic was aware of and complied with the requirements of the Duty of Candour.

We identified areas where the service could improve and should:

  • Review processes to devise and maintain a regular programme of premises checks, such as fire, health and safety, legionella, infection control and electrical safety.
  • Review the business continuity plan.
  • Review system for undertaking quality improvement for patients.
  • Review staff training to ensure all staff undertake role specific training.
Inspection areas

Safe

Updated 4 July 2018

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

  • We found there was an effective system for reporting and recording significant events, one event had been reported during the previous year. There were systems to help ensure that if things went wrong patients were informed as soon as practicable, received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices to minimise risks to patient safety, however on the day of the inspection some of the process had not been fully implemented, after the inspection we saw evidence that process were fully in place.

  • Staff demonstrated that they understood their responsibilities. All staff had received the relevant level of training on safeguarding children and vulnerable adults relevant to their role.

  • Records were kept securely electronically and they were clear, accurate and auditable.

  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.

  • The practice had adequate arrangements to respond to emergencies and major incidents, however the business continuity plan needed to be amended to include utility contact details.

Effective

Updated 4 July 2018

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

  • Staff were aware of current evidence based guidance and acted upon it.

  • The service referred to NaTHNaC, (National Travel Health Network & Centre) a UK government organisation which produces travel health guidance for healthcare professionals and TRAVAX (an interactive website providing up to the minute travel health information for health care professionals) for travel vaccination guidance.

  • The service had not undertaken any audits, the service showed us a schedule of audits which they would undertake following the inspection.

  • Staff sought and recorded patients’ consent to care and treatment and understood the requirements of legislation and guidance when considering consent.

  • Staff had the skills and knowledge to deliver effective care and treatment.

  • There was evidence of a system for appraisals in place and personal development plans for all staff, all staff appraisals were scheduled for May 2018.

Caring

Updated 4 July 2018

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

  • Staff we spoke with were aware of their responsibility to respect people’s diversity and human rights.
  • All of the seven patient Care Quality Commission comment cards we received were positive about the service experienced. Patients said they felt the provider offered an excellent service and staff were helpful, caring and treated them with dignity and respect.

  • Patients’ medical records were all stored securely electronically, only clinical staff could access patient records.

  • The provider maintained patient and information confidentiality.

Responsive

Updated 4 July 2018

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

  • The service provided an information leaflet detailing services offered, length of appointment times including a price list.

  • All patients’ appointments were pre-bookable and the service offered 15 to 30-minute consultations.

  • The GP service would see children from birth, the immunisation service was accessible to babies from two months old, however since the service had been running they had only seen adults.

  • The service had good facilities and was well equipped to treat patients and meet their needs. The premises were wheelchair accessible. The service had arrangements with the building next door if patients required baby changing facilities.

  • Information about how to complain was available. There was a policy on handling complaints that included processes for learning from complaints.

  • The service displayed posters for chaperoning.

Well-led

Updated 4 July 2018

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

  • The service had a clear vision and strategy to deliver high quality care.

  • There was a clear leadership structure and staff felt supported by management. The policies and procedures to govern activity were effective and had all been reviewed.

  • An overarching governance framework supported the delivery of the strategy and good quality care.

  • The service had a set agenda and undertook governance meetings every two months.

  • Staff were scheduled to have annual performance reviews and attended staff meetings and training opportunities.

  • The service was aware of the requirements of the duty of candour.
  • There was a culture of openness and honesty.

  • The service had systems for knowing about notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.

  • The service sought feedback from staff and patients.

  • There was a focus on continuous learning and improvement at all levels.