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Inspection Summary


Overall summary & rating

Updated 10 August 2018

We carried out an announced comprehensive inspection on 7 June 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.

LMCS Limited is located 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.

Eight 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 provider carried out recruitment checks for new staff.
  • 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 the complaints procedure was accessible to patients.
  • Governance arrangements were in place and staff felt supported, respected and valued by the provider.

There were areas where the provider could make improvements and should:

  • Review the equipment in place to respond to medical emergencies.
  • Develop quality improvement activity particularly in relation to clinical audit.
  • Review policy in relation to requesting proof of ID from patients on registering with the service.
  • Review policy in relation to ensuring that adults accompanying child patients have the authority to do so and provide consent on their behalf.
  • Review the vision and strategy for the service.
Inspection areas

Safe

Updated 10 August 2018

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

  • The clinic was equipped to respond to medical emergencies although there was no immediate access to a defibrillator or a risk assessment in place to mitigate the risks.

  • We found the clinic to be clean and hygienic and staff had received training on infection prevention and control. Infection control audits had not been undertaken to monitor infection control standards. However, following the inspection the provider sent us evidence of a completed infection control audit.

  • The provider carried out recruitment checks for new staff.

  • There was a health and safety policy and the provider had undertaken risk assessments to monitor the safety of the premises.

  • There was no system in place to receive and comply with national patient safety alerts from the Medicines and Healthcare Products Regulatory Authority (MHRA). However, the provider sent us evidence after the inspection that they had signed up to receive safety alerts.

  • There was system in place for reporting, investigating and learning from significant events.

We found areas where improvements should be made relating to the safe provision of treatment. This was because the provider did not request proof of ID from patients on registering with the service and did not ensure that adults accompanying child patients had the authority to do so and provide consent on their behalf. There was no defibrillator for use in the event of a medical emergency and no risk assessment to mitigate the risk.

Effective

Updated 10 August 2018

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

  • The provider had systems in place to gain consent.

  • There was evidence that the practitioners kept up to date with developments in their field.

  • There was some evidence of quality improvement however it was limited particularly in relation to improving clinical outcomes.

  • There were no formal systems in place for staff induction and appraisal. However, following the inspection the provider sent us evidence to show that these systems had been put in place.

We found areas where improvements should be made relating to the effective provision of treatment. This was because there was limited evidence of quality improvement activity particularly in relation to clinical audit.

Caring

Updated 10 August 2018

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

  • Staff treated service users with kindness, respect and compassion.

  • Privacy and confidentiality was upheld.

  • Feedback from patients was very positive in relation to the caring aspects of the service provided.

  • The provider involved patients and parents of patients in decisions about care and treatment.

Responsive

Updated 10 August 2018

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

  • The service organised and delivered services to meet patients’ needs.

  • Patients could access the service in a timely way.

  • There was a complaints policy and the complaints procedure was accessible to patients.

Well-led

Updated 10 August 2018

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

  • There was an informal vision to continue to improve the service however there was no strategy or supporting business plans to deliver the vision.
  • Governance arrangements were in place.
  • On the day of the inspection we identified some shortfalls in relation to providing well-led care. However, following the inspection the provider sent us evidence to show that the shortfalls had been rectified.
  • There was a positive culture and staff felt supported by the provider.
  • The provider proactively sought feedback from patients.