All inspections: Queens Clinic - Care Quality Commission

This service is rated as inadequate overall. The service had previously been inspected on 13 February 2020, 9 February 2021, 2 September 2021, 30 November 2021, 2 September 2022 and 30 September 2022, and in each case, there were breaches of CQC regulations.

Following the inspection on 30 September 2022, the service was rated as inadequate overall, and in the effective and well led key questions. The safe key question was rated as requires improvement, and the responsive and caring key questions were rated as good. The service was found to be in breach of regulations 17 and 18 of Health and Social Care Act (HSCA) (RA) 2014 and warning notices were put in place. The specific issues found at the inspection of 30 September 2022 were:

During surgical procedures undertaken under local anaesthetic, the surgeon was the only regulated health professional present, which had not been risk assessed.
Some clinical records were either incomplete or unclear.
The service had not undertaken any two cycle or outcome-based audits.
Consent procedures at the service were not adequate.
A lack of explicit detail in clinical records meant that it was not possible to ascertain what procedures had been carried out.
Staff at the service had not been appraised.
The service had not developed leadership and governance procedures to address breaches of CQC regulations identified in previous inspections.
There was a lack of clear clinical governance procedures at the service to show that the service was providing safe and effective care.

We carried out an announced comprehensive inspection of Queens Clinic on 16 and 24 January 2024, to review the breaches of regulation. We found that the breaches of regulation from the previous inspection had not been addressed, and other issues of concern were found. Following this inspection, the service is rated as inadequate overall and the key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Not rated

Are services responsive? – Good

Are services well-led? – Inadequate

Our key findings from this inspection were:

The service had some systems to manage risk. However, the service was not following safeguarding best practice and its own safeguarding policy. In addition, the service had limited quality improvement mechanisms in place, so it was unclear how the service was determining if the care was of sufficient standard, and that incidents were not being missed.
The service undertook procedures under local anaesthetic, but in the event of an adverse reaction to local anaesthetic, the lead clinician was the only person available to manage this. The lack of a second clinician had not been adequately risk assessed.
The service had not reviewed the effectiveness and appropriateness of the care it provided.
A review of clinical records and consent forms found we were not consistently able to ascertain what procedures had been undertaken, or what consent process had been followed, including the explanation of risks and provision of information. In some instances, attendances at the clinic were not accompanied by a consultation note. There were also examples where it was unclear what protocols and guidance the provider had followed in providing treatment.
Staff treated people with compassion, kindness, dignity and respect.
Patients were able to access care and treatment from the service. An adequate complaints system was in place.
Governance systems, particularly those that ensured safe and effective care, were ineffective and unclear.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of safe care and treatment.
Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance.
Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good staffing.

This service was placed in special measures in September 2022. Insufficient improvements have been made such that there remains a rating of inadequate overall and for the safe, effective and well led key questions. Therefore we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration if they do not improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

This service is rated as inadequate overall. The service had previously been inspected on 13 February 2020, 9 February 2021, 2 September 2021 and 30 November 2021, and in each case, there were breaches of CQC regulations. Following the inspection on 30 November 2021 the service was rated as requires improvement overall, and in the safe, effective and well led key questions. The responsive and caring key questions were rated as good. The service was found to be in breach of regulations 12, 17 and of HSCA (RA) 2014 and requirement notices were put in place. The specific issues found at this inspection were:

The oxygen bottle in place at the surgery was noted to be empty at the time of the inspection.
The service did not own its own defibrillator but shared one with another organisation in the building. Staff at the service were unaware of where this was located, and by the time it was found and staff returned to the clinic, five minutes had passed.
Learning from incidents was not routinely shared within the team.
Learning from audits was unclear. Audits completed were not recorded in cycles, and as such it was not possible to determine whether or not performance had improved.
The practitioner did not routinely send out letters to patients in a password protected format.
On the day of the inspection, neither the lead clinician or service manager were able to show completed fire safety or information governance training.
We spoke to several staff who either worked at the clinic or had worked there in the past. They told us that there was a non-supportive culture at the service. Several reported being publicly criticised by the provider, and they stated that they had no autonomy. They reported being afraid to raise issues of concern with the provider.
The service did not have either a risk register or other formal way of showing that risks were being identified, recorded, monitored and mitigated.

We carried out an announced comprehensive inspection of Queens Clinic on 30 September 2022. We found that some of the breaches of regulation from the previous inspection had been addressed, but others had not. Following this inspection, the key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

Our key findings were:

The service had good systems to manage risk in most areas so that safety incidents were less likely to happen. The service had limited quality improvement mechanisms in place, so it was unclear how the service was determining if the care was of sufficient standard, and incidents were not being missed.
The service undertook procedures under local anaesthetic, but in the event of an adverse reaction to local anaesthetic, the lead clinician was the only person available to manage this. The lack of a second clinician had not been adequately risk assessed.
The service had not reviewed the effectiveness and appropriateness of the care it provided. Records reviewed were also unclear regarding the exact nature of procedures, and what had been discussed with the patient.
Staff at the service had not received appraisals.
Staff treated people with compassion, kindness, dignity and respect.
Patients were able to access care and treatment from the service. An adequate complaints system was in place.
The organisation had appropriate leadership structures in place. However, governance systems, particularly those whereby learning could be demonstrated, were unclear.
The service had not addressed issues identified as requiring improvement in previous CQC inspections, and continuing breaches of CQC regulations were evident.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance.
Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good staffing.

The service should:

Review the notes tracker on the patient records database, which was incomplete.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

This service is rated as Requires Improvement overall. The service had previously been inspected on 13 February 2020, 9 February 2021 and 2 September 2021. Following the inspection on 9 February 2021 the service was rated as inadequate overall, and in the safe, effective and well led key questions. The responsive key question was rated as requires improvement, and caring was rated as good. The service was found to be in breach of regulations 12 and 17 of HSCA (RA) 2014 and urgent conditions were placed on the registration of the service. The specific issues found at the inspection were:

Clinicians were not kept up to date with current evidence-based practice.
Lack of understanding of the requirements of legislation and guidance when considering consent and decision making.
They responded to all complaints, including informal ones in line with their complaints policy.
Not all staff had the appropriate level of Disclosure and Barring Service check (DBS) check carried out.
The staff that acted as chaperones had not received training for this role.
The service did not have full infection control procedures in place.
The care records were not clear as we found it was difficult to follow the reason for diagnosis or treatment rational.

We carried out an announced comprehensive inspection of Queens Clinic on 30 November 2021. At the time of the inspection the location was closed, but has subsequently re-opened. We are mindful of the impact of COVID-19 pandemic on our regulatory function. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We found that some of the breaches of regulation from the previous inspection had been addressed, but others had not. Following this inspection, the key questions are rated as:

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

Our key findings were:

The service had good systems to manage risk in most areas so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes. However, learning from incidents was not clearly demonstrated.
At the time of the inspection, equipment required in an emergency was either not in place, or was not sufficiently accessible at the service.
The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
The organisation did not have sufficient procedures in place to ensure that effective staffing was being provided.
Staff involved and treated people with compassion, kindness, dignity and respect.
Patients were able to access care and treatment from the service. An adequate complaints system was in place, but the process for learning from complaints was not formalised.
The organisation had appropriate leadership functions in place. However, governance systems, particularly those whereby learning could be demonstrated, were unclear.
Staff and former staff that we spoke to stated that the culture of the organisation was not supportive, and that they were not listened to. They reported that they were afraid to raise concerns.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure that care and treatment is provided in a safe way to patients. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good staffing. Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service should:

Undertake two-cycle audits to demonstrate quality improvement.

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

This service was not rated in this report, and the overall rating remains inadequate.

We carried out an unannounced focussed inspection on 2 September 2021 in response to information of concern that we received. The focussed inspection looked only at the area of infection control, and did not review progress against any of the other breaches detailed in the report following CQC’s previous inspection on 9 and 10 February 2021.

The inspection of 2 September 2021 found there had been insufficient improvement in the area of infection control, and we identified further concerns.

Our key findings were:

The service did not have full infection control procedures in place.
The service did not have sufficient risk processes and procedures in place to mitigate the risk of transmission of Covid 19.
A clinician at the service had consulted with patients at a time when they either knew or suspected that they had contracted Covid 19.

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.

This service was placed in special measures following our previous inspection of 9 and 10 February 2021. Insufficient improvements have been made in the area of infection control. Therefore, we are taking action in line with our enforcement procedures and have urgently suspended the service until 3 December 2021. A further comprehensive inspection of the service will take place before this date, and if insufficient improvement is made, this will lead to cancelling of the service’s registration. The service will be kept under review and if needed could be escalated to urgent cancellation of their registration.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

This service is rated as Inadequate overall. (Previous inspection February 2021 – Requires improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Queens Clinic on 9 & 10 February 2021 in response to information of concern that we received and to follow up on breaches of regulation identified in a comprehensive inspection carried out in February 2020 where we found:

The provider had not established effective systems and processes to demonstrate positive clinical outcomes for patients through continuous quality improvement activities and audits.
There were no systems to ensure appropriate action was taken in response to safety alerts.
All patient records did not detail clinical decisions and the reasons for not following national guidelines.
Recruitment procedures were not always followed, and appropriate checks were not completed prior to new staff starting employment.
Not all staff received appropriate training for their role, including safeguarding adults and children and fire safety.

This inspection on 9 & 10 February 2021 found insufficient improvements have been made and we identified further concerns.

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations

This service provides gynaecological services and advise to fee paying patients. The provider is the 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.

Our key findings were:

Not all staff had the appropriate level of Disclosure and Barring Service check (DBS) check carried out
The staff that acted as chaperones had not received training for this role
Not all staff had the skills, knowledge and experience to carry out their roles. Some staff had not received specific training for their role
The service did not have full infection control procedures in place.
The care records were not clear as we found it was difficult to follow the reason for diagnosis or treatment rational
We found staff did not understand what constituted a significant event
The provider did not have systems to keep clinicians up to date with current evidence-based practice
The service was not actively involved in quality improvement activity
Staff did not understand the requirements of legislation and guidance when considering consent and decision making
Staff did not recognise the importance of people’s dignity and respect
The service did not have a strategy or business plan in place
There were no systems to support improvement and innovation work
Patients were able to access care and treatment from the service within an appropriate timescale for their needs

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.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Improve staff’s recognition around the importance of people’s dignity and respect when giving treatment.
Review communication aids in place to support patients who were hard of hearing.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Queens Clinic as part of our inspection programme. This service provides gynaecological services and advise to fee paying patients.

The provider is the 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.

Thirty-three patients provided feedback about the service to CQC. All patients said the service was of a high standard and that staff members were all kind and helpful.

Our key findings were:

Not all staff had received mandatory training relevant to their role. The doctor did not have the appropriate level of safeguarding training for adult and children. The provider could not demonstrate staff had received fire safety training.
Where the service did not follow national guidance relating to effective treatment, there was not always a clear rationale documented in patients’ records.
There governance systems in place were not always effective in overseeing risk.
Staff involved and treated people with compassion, kindness, dignity and respect.
Patients could access care and treatment from the service within an appropriate timescale for their needs.
Staff said that they felt happy to raise concerns or issues to the provider.

The areas where the provider must make improvements as they are in breach of regulations are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure all staff receive the appropriate training to enable them to carry out their role.

The areas where the provider should make improvements are:

Review service policies to ensure they are service specific, including business continuity plan.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Queens Clinic

All Inspections

16 and 24 January 2024

During a routine inspection

30 September 2022

During a routine inspection

30 November 2021

During a routine inspection

02 September 2021

During an inspection looking at part of the service

9 & 10 February 2021

During a routine inspection

13 Feb 2020

During a routine inspection