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Inspection Summary


Overall summary & rating

Good

Updated 22 October 2019

This service is rated as Good overall.

This service has been inspected previously, but not rated. Those reports can be found by selecting the ‘all reports’ link for LMCS Ltd on our website at www.cqc.org.uk.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive at LMCS Ltd on 31 May 2019 as part of our inspection programme.

LMCS Limited is in Edgware in the London borough of Brent.

The services doctor 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.

Twenty people provided feedback about the service through Care Quality Commission comment cards. The feedback received was all positive.

Our key findings were:

  • The clinic was clean and hygienic, and staff had received training on infection prevention and control.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When safety incidents did happen, the service learned from them and improved their processes.
  • Staff treated service users with kindness, respect and compassion and their privacy and confidentiality was upheld.
  • Feedback from patients was very positive in relation to the quality of service provided.
  • Patients could access the service in a timely way.
  • There was a complaints policy and procedure, both of which were accessible to patients.
  • Governance arrangements were in place and staff felt supported, respected and valued by the provider.

We rated effective as requires improvement because:

  • The service did not always review the effectiveness and appropriateness of the care it provided. It did not ensure that care and treatment was delivered according to evidence-based guidelines.
  • Quality improvement activity, systems and processes were not comprehensive and there was limited evidence to show the provider reviewed the effectiveness of the care and treatments provided.
  • Consent processes for children requiring care and treatment did not follow General Medical Council guidance for obtaining consent from all adults with parental responsibility.

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

  • Ensure systems are implemented to assess, monitor and improve the quality and safety of the service provided.
  • Ensure systems are implemented to mitigate risks relating to the health, safety and welfare of services users.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 22 October 2019

We rated safe as

Good because:

Safety systems and processes

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

  • One of the practitioners was the lead for safeguarding and there were policies in place covering adult and child safeguarding which included the contact details of the local safeguarding team.
  • Staff had completed safeguarding training to the appropriate level. For example, the circumcision practitioners had completed training to level three, the assistant and reception staff to level two.
  • The provider carried out recruitment checks for all new staff members including proof of identity and evidence of satisfactory conduct in previous employments. Disclosure and Barring Service (DBS) checks had been undertaken for all staff. (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).
  • The clinic sterilised circumcision equipment on-site. We saw that there was a process in place for decontamination including a dirty to clean flow. All staff had received training on infection control.
  • The clinic used a sterilising machine which was maintained appropriately.
  • Body fluid spillage kits were in place and the immunity status of all clinical staff was recorded.
  • The provider had carried out an infection control audit in July 2018 which recorded no risks or need for change to take place.
  • There was a health and safety policy and the provider had undertaken risk assessments to monitor the safety of the premises. This included risk assessments for the control of substances hazardous to health (COSHH), fire safety and legionella and water hygiene (Legionella is a term for a bacterium, which can contaminate water systems in buildings).
  • Staff had completed training modules on COSHH and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).
  • The provider had ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There was evidence of portable appliance test (PAT) and medical equipment calibration tests having been completed in May 2018 and we saw evidence of further testing and calibration having been booked to occur within the following week. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them.
  • The practitioner, who was a registered doctor, was up to date with appraisal and revalidation. The Practitioner who was a dentist was not subject to revalidation but met regularly with the doctor to discuss cases and best practice.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. All staff had received annual basic life support training.
  • Appropriate emergency medicines were available and fit for use. There was a system in place to check expiry dates and all the medicines we checked were in date.
  • There was an oxygen cylinder available in the surgery room and, since the previous inspection, we saw that there were paediatric masks available.
  • We also saw that a defibrillator had been purchased since the last inspection, and that regular checks on its operation were being undertaken.
  • There was a business continuity plan for major incidents such as power failure or building damage and we saw that it contained all the appropriate supplier contact details should they be needed.
  • We saw evidence of appropriate indemnity arrangements in place which specifically covered liabilities that might arise from procedures taking place within a child and adult male circumcision clinic.

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 written and managed in a way that kept patients safe. We looked at six care records which all 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.
  • Identification was requested when patients or their parents registered with the service and checks were made to ensure that adults accompanying child patients had the authority to provide consent on their behalf.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance if they cease trading.

Safe and appropriate use of medicines

  • The provider could prescribe medicines if needed following the surgical procedure.

  • Local anaesthetic was used and was stored in the surgery room. There were systems in place to check the expiry date of local anaesthetic and the batch number and expiry date were recorded in the patient notes.

Track record on safety

The service had a good safety record.

  • There were risk assessments in place in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving and acting on safety alerts, and a record was kept of action taken in respect of alerts which were relevant to the service.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • The practitioner we interviewed, understood what constituted a serious incident or significant event and was aware of the legal requirements of the duty of candour.
  • The system for reporting, investigating and learning from significant events had been by using an accident book where work related injuries were also recorded. Since the last inspection, however, a policy for dealing with significant events and a formal system had been introduced to record, investigate, act on and learn from significant events and adverse incidents. There had been no incidents recorded during the last 12 months and all staff were aware of what would constitute a significant event.
  • The service encouraged a culture of openness and honesty.

Effective

Requires improvement

Updated 22 October 2019

We rated effective as Requires improvement because:

  • The service did not always review the effectiveness and appropriateness of the care it provided. It did not ensure that care and treatment was delivered according to evidence-based guidelines.
  • Quality improvement activity, systems and processes were not comprehensive and there was limited evidence to show the provider reviewed the effectiveness of the care and treatments provided.
  • Consent processes for children requiring care and treatment did not follow General Medical Council guidance for obtaining consent from all adults with parental responsibility.
  • Although staff sought and recorded patients’ identification and consent to care and treatment, they did not always record joint consent in line with legislation and guidance.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed patient needs but there were risks they did not always deliver care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • Due to the nature of the service, there was no system in place to ensure the practitioners were up to date with recognised guidance such as guidance from the General Medical Council, British Medical Association and The National Institute for Health and Care Excellence (NICE).The practitioner we interviewed told us they kept up to date on new developments by reading research papers and they provided an example of recent updates they had read on post-operative bleeding and how they had incorporated the learning into clinical practice. They confirmed that they would be signing up to receive NICE guidance alerts. Following the inspection, the provider advised that the two doctors had signed up for NICE and MHRA alerts. However, there was nothing presented to evidence this.
  • Patients and parents of children and babies using the service had an initial consultation, where a detailed medical history was taken. Parents of patients and others who used the service were able to access detailed and clear information regarding the process and the different procedures that were provided. This included advice on post-operative care. If the initial assessment identified that the patient was unsuitable for the procedure this would be documented, and the patient referred to their own GP. After the procedure clinicians discussed after care treatment with parents and sought to inform them of what to expect over the recovery period. This was both to reduce concern and anxiety from the parents and to prevent them unnecessarily attending other primary or secondary care services.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

  • There was limited evidence of audited quality improvement as patients did not re-attend due to the specialist nature of the service provided. Following the previous inspection, the practitioner had introduced a follow up form which was completed four weeks after the procedure so that they could record any instance of post operation issues or infections. We were told that there were no instances of post-operation infection or issues during the last 12 months.
  • There had been one medical review completed which the practitioner had carried out as a mandatory requirement of revalidation. The review was carried out to check the standard of patient’s records. The results of the review showed that no actions were necessary.

Effective staffing

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

  • All staff were appropriately qualified or had received extensive training. The doctor working in the service had significant experience in this area of work and was a member of the Royal College of Surgeons. They provided extensive training to the dentist performing non- therapeutic interventions. The provider had an induction programme for all newly appointed staff.
  • 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 and this included details of training on infection control, safeguarding children and adults, the Mental Capacity Act, basic life support, information governance, violence and aggression and record keeping.

Coordinating patient care and information sharing

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

  • All patients, or their parents, were asked for consent to share details with their usual GP of their consultation and of the procedure performed and the reasons for requesting this were explained. If the patient had been referred by a GP, the patient or parent was given a letter to give to the GP so that their medical record could be updated with details of the procedure. It also contained advice be given to the GP on any post circumcision issues.

Supporting patients to live healthier lives.

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave patients or their parents advice, so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support by means of a letter given to patients or parents after the procedure.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

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

  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
  • At our last inspection we noted that the policy in relation to requesting proof of ID from patients on registering with the service. However, the policy in relation to ensuring that all adults with parental responsibility for the child have the authority to provide and also all parties give consent, required improvement. At this inspection we saw evidence of new forms which were completed at the time of registration and which recorded the required information. If both parents were present, then consent was given jointly. However, the provider did not follow General Medical Centre guidance in relation to obtaining consent from all adults with parental responsibility of the child in all but extenuating circumstances.
  • Although the policy of the service was not to provide either therapeutic or non-therapeutic circumcisions should these forms not be completed or if there was any doubt as to the authority of the person accompanying the patient to provide appropriate consent, there was no stipulation that joint consent had to be given and, in some cases, procedures were completed with the consent of just one parent.
  • Following the inspection, the provider advised they would amend their consent forms and policy to ensure that both parent and guardian consent would be collected and where this wasn't possible, the circumcision procedure would not be undertaken. However, there was no evidence to demonstrate this had been implemented.
  • When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance.

Caring

Good

Updated 22 October 2019

We rated caring as Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • From 172 reviews received over a two-year period, 167 were very positive about the service. The reviews demonstrated a high level of satisfaction with the service provided.
  • 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.

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had enough time during consultations to make an informed decision about the choice of treatment available to them and their children.
  • Staff told us that they spent time with parents both pre and post procedure carefully explaining the circumcision and recovery process to reduce any anxieties they may have.
  • 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 room to discuss their needs.
  • Staff told us that doors were closed during consultations and therefore conversations taking place in the surgery room could not be overheard.
  • Staff were aware of the importance of confidentiality and they had received training on information governance.

Responsive

Good

Updated 22 October 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 and provided services in response to those needs.
  • The facilities and premises were appropriate for the services delivered.
  • The service was offered on a private, fee-paying basis only, and as such was accessible to people who chose to use it and who were deemed suitable to receive the procedure. The provider was open and transparent about fees which were displayed on the clinic website and available at the clinic.
  • Follow-up appointments were available if required and available until the circumcision had healed.

Timely access to the service

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

  • The opening hours of the clinic were 9am to 5pm Monday to Friday and 10am to 3pm Saturdays.
  • Appointments for non-therapeutic circumcisions were available, with the practitioner who was a registered dentist, from Tuesday to Saturday. Appointments for therapeutic circumcisions were available, with the practitioner who was a registered doctor, from Monday to Saturday for two weeks per month. We were told that most circumcisions were for non-therapeutic reasons.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available.
  • There had been no complaints in the previous two years. Prior to this there was evidence of one complaint which had been dealt with appropriately. The provider had learnt from that complaint and this had led to a change of practice which was the implementation a circumcision procedure checklist.
  • Staff would treat patients who made complaints compassionately.
  • The service had complaints policy and procedures in place.

Well-led

Good

Updated 22 October 2019

We rated well-led as Good

because:

Leadership capacity and capability

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

  • Both practitioners were knowledgeable about issues and priorities relating to the quality and future of the services provided.
  • Leaders were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. The practitioner, who was a registered dentist, had been delegated responsibility for the organisational direction and development of the service and the day to day running of the clinic.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was an informal vision and set of values, which all staff were aware of. Following the inspection, the provider submitted a vision statement and strategy which was not comprehensive. We have not been able to test how this has been implemented or embedded within the service.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included regular annual appraisals in the last year. All staff were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • The practitioner who was a registered dentist had been delegated responsibility for most aspects of governance including safeguarding, incident reporting, infection control, complaints and information governance. Clinical oversight was shared between the two practitioners with overall responsibility laying with the registered doctor.
  • Non-clinical staff were aware of their own roles and responsibilities, and the roles and responsibilities of others.
  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • Staff meetings were held on a regular basis and there was documented evidence of minutes of those meetings.

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.
  • Leaders had oversight of safety alerts, incidents, and complaints.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service submitted data or notifications to external organisations as required.
  • 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 encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture.
  • The provider proactively encouraged patients to provide feedback on the service through online reviews, a form on the clinic website and through text messaging. They had developed a guide for service users on how to write an online review.
  • We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.

Continuous improvement and innovation

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

  • Although there had been no recorded complaints or significant events, the service had the appropriate processes and procedures in place.
  • There was no comprehensive programme of quality improvement.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The provider had audited service user feedback and responded to both positive and negative comments.