The Wells Clinic at Robert Denholm House

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

We carried out a comprehensive inspection of The Wells Clinic at Robert Denholm House on 23 July 2019. We identified breaches of regulation 9 (Person-centred care), regulation 17 (Good governance) and regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued requirement notices. The service was rated as inadequate for providing safe services, requires improvement for providing effective and well-led services and good for providing caring and responsive services. The service was rated as requires improvement overall.

We carried out this announced comprehensive inspection of The Wells Clinic at Robert Denholm House between 5 and 10 August 2021 under Section 60 of the Health and Social Care Act 2008. 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. At this inspection we checked that the service was providing safe, effective and well-led services.

Throughout the COVID-19 pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Speaking with staff in person and using video conferencing.
• Requesting documentary evidence from the provider.
• A site visit.

We carried out an announced site visit to the service on 9 August 2021. Prior to our visit we requested documentary evidence electronically from the provider. We spoke to staff by telephone and using video conferencing, prior to and following our site visit.

The Wells Clinic at Robert Denholm House is an independent provider of a range of GP services, including consultations, child and adult immunisations, travel health advice and vaccinations, well man and woman health checks and cervical screening. Botox (Botulinum toxin) injections are provided for the treatment of excessive sweating. A minor surgery service is provided which includes the excision of moles and other lesions. The service is registered with the National Travel Health Network and Centre (NaTHNac), as a Yellow Fever Vaccination Centre.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Wells Clinic at Robert Denholm House also provides a wide range of non-surgical aesthetic interventions. This includes cosmetic Botox injections, dermal fillers and facial peels, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The Wells Clinic at Robert Denholm House is registered with the Care Quality Commission to provide the following regulated activities: Treatment of disease, disorder or injury and Surgical procedures. Prior to our inspection we identified that the provider was carrying out the excision of skin lesions and sending those tissue samples for histological review without being registered to provide the required regulated activity Diagnostic and screening procedures. The provider immediately submitted an application to provide Diagnostic and screening procedures as a regulated activity.

The service director 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:

• Staff had received training in key areas. There was a clear plan of training for staff. There was comprehensive monitoring of training undertaken by clinical staff employed on a sessional basis.
• There were processes in place for performance review, clinical supervision and monitoring/oversight of clinical staff employed on a sessional basis. Staff employed by the service had undergone appraisals.
• There were effective systems and processes to assess monitor and control the spread of infection.
• There were safeguarding systems and processes to keep people safe. Staff had received training in the safeguarding of adults and children.
• Arrangements for chaperoning were effectively managed. Staff had received chaperone training and had been subject to Disclosure and Barring Service (DBS) checks.
• There were appropriate arrangements to manage medical emergencies and suitable emergency medicines and equipment in place.
• Fire safety processes were in place. Staff had participated in fire drills and had received fire safety training.
• There were general health and safety and premises risk assessments in place. There were arrangements for regular review of leasing arrangements with premises managers.
• Clinical record keeping was clear, comprehensive and complete.
• There was some evidence of clinical audit and regular auditing of clinical record keeping processes.
• There were clear and improved governance and monitoring processes to provide assurance to leaders that systems were operating as intended. Risks were promptly identified and responded to.
• Best practice guidance was followed in providing treatment to patients. For example, excised lesions were routinely sent for histological review.
• There were comprehensive records to demonstrate that recruitment checks had been carried out in accordance with regulations, including for staff employed on a sessional basis.
• Staff found leaders highly approachable and supportive and felt they provided an individual service to patients.
• Policies and procedures were monitored, reviewed and kept up to date with relevant and sufficient information, to provide effective guidance to staff.
• There was frequent and open communication amongst the staff team which was well documented and monitored to ensure agreed actions were completed.
• Service users were routinely asked to provide feedback on the service they had received. Complaints were managed appropriately.

The areas where the provider should make improvements are:

• Establish arrangements for the retention of all records which relate to staff immunisation status.
• Develop clinical audit processes further, to include additional clinical conditions.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care