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Inspection carried out on 31/05/2019

During a routine inspection

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 carried out on 7 June 2018

During a routine inspection

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.

During a check to make sure that the improvements required had been made

The provider had made the required improvements by ensuring the necessary pre-employment checks had been carried out for all staff.

Inspection carried out on 13 December 2013

During a routine inspection

During this inspection, there were no patients present. However we were able to view completed feedback forms from patients and their relatives. The feedback indicated that people were satisfied with the care and treatment provided. One patient stated, "very nice atmosphere. Staff made me feel so comfortable and relaxed. I would recommend the clinic". Another patient said, “I was pleased with the overall experience".

The receptionist and registered manager who was also the clinic’s surgeon were aware that all patients who used the service should be treated with respect and dignity. They were also aware of the importance of protecting the privacy of patients. The receptionist confirmed that the door was closed whenever patients were being attended to.

Records indicated that patients were carefully assessed and the surgical procedure had been explained to them. The surgeon had updated his medical knowledge and skills. The operating room was clean. Information regarding problems and complications which may occur after circumcision was available for patients and their representatives. Emergency medication were within their use by dates.

The service had a recruitment policy. However, one staff did not have a criminal records disclosure prior to starting work. This is needed for the protection of patients. A compliance action has been made in respect of this deficiency.

Staff were aware of the complaints policy and procedure. No complaints had been recorded since the last inspection. The surgeon stated that none had been received.

Inspection carried out on 21 February 2013

During a routine inspection

We observed people were asked by the surgeon and surgery staff to consent to the procedure and side effects as well as complications were explained in detail.

We viewed detailed evidence of the above and relatives spoken with told us that they had visited the surgery for three different procedures and on every occasion the surgeon followed this assessment and treatment plan. A relative told us, "we would not return and recommend the surgery if we would not be fully satisfied with the service."

A comment made on the surgery website. "I was very worried and able to cancel surgery at any time while I am there, the clinic is a small place that worried me more, but I went for it. I was really happy the way it was handled, I will recommend it to everyone, very clean, and my son healed in 3 days."

Our first impression was the surgery was absolutely spotless. We asked a patient who visited the surgery before if that had been the case in the past. The patient told us, "the surgery is even cleaner then it was in the past."

Patients and relatives made positive comments about staffing. "The clinic was very neat and the staff were highly trained, helpful and had an excellent customer service with 5 star rating."

We found on the surgery’s website extensive evidence of positive comments made by patients and their relatives about treatment and care received from LMCS Limited.