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This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating


Updated 13 June 2019

Inspection areas



Updated 13 June 2019

Safety systems and processes

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

  • Arrangements for safeguarding reflected relevant legislation and local requirements. Policies were accessible to staff. The policies clearly outlined who to contact for further guidance if staff had concerns about a patient’s welfare.
  • There was a clinical and non-clinical lead for safeguarding. We saw that both had been trained to safeguarding children level 3.
  • Staff we spoke with demonstrated they understood their responsibilities regarding safeguarding and knew who the safeguarding leads were. We saw evidence that clinical and non-clinical staff had received safeguarding training appropriate to their role.
  • The service had a system in place to assure that an adult accompanying a child had parental authority and we saw evidence of where this had been verified.
  • Staff who acted as chaperones were trained for the role and had received an enhanced Disclosure and Barring Service (DBS) check. 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 provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Staff immunisation was maintained in line with current Public Health England (PHE) guidance which had been a recommendation from our previous inspection. DBS checks were undertaken on all staff in line with the provider’s policy. Clinical staff had professional indemnity insurance that covered the scope of their private practice.
  • We observed that the premises were clean and tidy. Storage and segregation of cleaning equipment posed a potential risk of cross-contamination and were stored in an unlocked cupboard. Immediately after the inspection the service sent evidence that appropriate storage had been established and a locked had been fitted to the storage door.
  • The service had an Infection Prevention and Control (IPC) policy in place which was accessible to staff. The service had nominated a healthcare assistant as infection prevention and control (IPC) lead who had undertaken training. An IPC audit had been undertaken as well as daily room checks to ensure they were clean and had adequate supplies, for example, personal protective equipment (PPE), sharps bins and couch rolls. Both clinical and non-clinical staff had undertaken IPC training, which had been a recommendation from our previous inspection for non-clinical staff to have access to formal training.
  • The arrangements for managing clinical waste and specimens kept people safe. We saw that appropriately colour-coded sharps containers were available for the range of medicines administered which had been a recommendation to review from our previous inspection.
  • The service was operating from leased premises and maintenance and facilities management was shared by the landlord and the tenant. We saw evidence that the fire alarm warning system and firefighting equipment was regularly maintained by an external contractor. Various risk assessments had been undertaken for the building, including health and safety, Control of Substances Hazardous to Health (COSHH) and fire. We saw that action had been taken to address the findings of the risk assessments. The landlord had undertaken water sample testing for Legionella but the service did not have access to the formal risk assessment undertaken by the landlord for the building and water temperature testing was not undertaken.
  • We saw evidence that portable appliance test (PAT) had been undertaken in August 2018. Calibration of medical equipment, such as vaccine fridges, weigh scales and blood pressure monitors, had been undertaken in February 2019. Equipment used for treatment and diagnostic purposes, for example, colposcope (used to examine the cervix), ultrasound machine and laser were on individual maintenance contracts. However, two maintenance contracts had recently expired. Immediately after the inspection the service sent renewed maintenance contracts and evidence that annual preventative maintenance had been scheduled.
  • The regulations for the safe use of laser equipment were being followed. There was a Laser Protection Advisor (LPA), a nominated individual as the Laser Protection Supervisor (LPS) and local rules for laser safety were in place. Only one member of the consultant team undertook laser treatment and we saw evidence of competence training and awareness of general precautions and protective equipment.

Risks to patients

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

  • At our previous inspection we found the service did not have systems in place to manage all potential medical emergencies and had not carried out a formal risk assessment to support their rationale. This included the availability of an external automated defibrillator (AED), medical oxygen and some emergency medicines, for example, atropine (used to treat bradycardia which may occur on intrauterine coil fitting). At this inspection, we found that the service had undertaken a formal risk assessment and had medical oxygen, with child and adult masks, and a range of emergency medicines. We reviewed the provider’s risk assessment and saw that the decision not to have an AED was based on the premises being a five-minute walk from the Chelsea and Westminster A&E department and their emergency procedure was to immediately phone emergency services. After the inspection, the provider reviewed their risk assessment in line with the Resuscitation Council (UK) guidelines and sent evidence that it had procured an AED and confirmed emergency medicines were available for the management of anaphylaxis (an acute allergic reaction), bradycardia (abnormally slow heart rate), suspected myocardial infarction (heart attack), nausea and vomiting, suspected bacterial meningitis, hypoglycaemia (low blood sugar) and asthma.
  • All clinical and non-clinical staff we spoke with knew how to respond to a medical emergency, knew the location of the emergency equipment and had undertaken basic life support and first aid training. Panic alarms had been installed in the downstairs clinical rooms since our last inspection.
  • The clinical staff we spoke with knew how to identify and manage patients with severe infections, for example, sepsis. Non-clinical staff we spoke with were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients but there had been no formal training on sepsis awareness. After the inspection the provider sent evidence that the clinical lead had delivered training to all non-clinical staff on the definition, risk factors and signs of sepsis including the action to take.
  • The service had a business continuity plan in place for major incidents such as power failure or building damage which included contact details of staff.
  • There were arrangements for planning and monitoring the number and mix of staff needed.

Information to deliver safe care and treatment

Staff had 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. Patient records were stored securely using an electronic record system. There were no paper records. Computers were password protected with restricted access dependant on role.
  • The care records showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems in place for seeking consent to share information with the patient’s NHS GP, if applicable. This was captured at the point of patient registration.
  • The service was able to describe the system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading but this was not formalised. Immediately after the inspection the service sent a formal protocol written in line with guidance.
  • There was a system in place for dealing with pathology results. Pathology specimens were sent to a professional laboratory for analysis. All specimens were collected by the laboratory directly from the service. Pathology results were securely received by the service and saved on the clinical record. The service had mechanisms in place to ensure consultants had communicated results with patients and acted upon findings. The provider told us there were effective lines of communication with the consultants and their secretaries in the management of patient results.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • At our previous inspection we found that the service did not have reliable systems in place for the appropriate and safe handling of medicines. Specifically, the provider was not compliant with the Medicines for Human Use 2012 Regulations (Schedule 26) with regards to the packaging requirements for dispensed medicines. At this inspection we found that the service had addressed our findings. We observed that all medicines were kept in a secure locked cupboard and only accessible to authorised individuals. All medicines we reviewed were in-date. The service did not stock controlled drugs. The service had clear procedures which covered all aspects of the dispensing process and a system to monitor staff compliance. Medicines were dispensed in original packaging and were appropriately labelled in line with guidance. It was the responsibility of the healthcare assistants to prepare the medicines for dispensing under instruction and review of the prescribing clinician.
  • For dispensed medicines, prescriptions were signed before medicines were handed out to patents and scanned onto the patient clinical record. We saw that prescription stationery was in the form of no carbon required (NCR) pads which enabled the provider to retain a copy to monitor and audit prescribing. At the time of the inspection these were not scanned onto the clinical system. After the inspection the provider sent evidence that it had updated its prescribing policy to include the scanning of all prescriptions issued onto its clinical system. We saw that the service had undertaken an audit of its dispensed and prescribed medicines for the period January and December 2018.
  • The service told us they did not prescribe controlled drugs and any high-risk medicines, e.g. warfarin, methotrexate, azathioprine or lithium which we confirmed on review of the prescribing audit.
  • Staff we spoke with demonstrated they prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance.
  • At our previous inspection, we found the under-counter vaccine fridge was overstocked and did not have sufficient space around the vaccine packages to allow air to circulate adequately. At this inspection, we found the service had procured an additional fridge which built-in thermometer. Both fridges had a secondary thermometer which had been a recommendation from our previous inspection. We saw evidence that the minimum, maximum and actual temperatures were recorded daily. All medicines we reviewed were in-date. We saw that the service had not taken steps to avoid the accidental interruption of the electricity supply to one of the medicines fridge, for example via a hard-wire fuse or by placing cautionary notices on plug and socket. The provider sent evidence after the inspection that a notice had been placed on the socket.

Track record on safety and incidents

The service had a good safety record.

  • There was a system for recording and acting on significant events and incidents. There was an incident policy in place which was accessible to staff. Staff we spoke with understood their duty to raise concerns and report incidents and near misses.
  • There was a formal system for receiving and acting on patient safety alerts which had been a recommendation from our last inspection and we saw evidence where recent alerts had been reviewed and action taken. However, we could not see evidence that a recent alert on the use of the medicine sodium valproate in pregnancy, which was relevant to the service portfolio, had been cascaded to clinical staff. Immediately after the inspection the provider sent evidence that the alert and guidance had been sent to all consultants and GPs who provide services at the centre.
  • There were comprehensive risk assessments in relation to safety issues.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • The provider told us they used every opportunity to learn from all incidents.
  • We saw that the service had adequately reviewed and investigated when things went wrong and took action to improve safety. We saw that incidents were discussed in meetings.
  • The service was aware of and complied with the requirements of the Duty of Candour. Staff we spoke with told us the service encouraged a culture of openness and honesty. When there were unexpected or unintended safety incidents the service gave affected people reasonable support, truthful information and a verbal and/or written apology.



Updated 13 June 2019



Updated 13 June 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • Arrangements were in place for a chaperone to be available, if requested.
  • The service gave patients timely support and information.
  • Feedback from patients through CQC comments cards was positive about the way staff treated people with patients describing staff as compassionate, understanding and reassuring.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • The service gave patients clear and comprehensive information to help them make informed choices, including the cost of services, on their website and in a patient brochure.
  • The service had acted upon some recommendations from our previous inspection and had formal interpretation services available for patients who did not have English as a first language and an induction hearing loop available for those with a hearing impairment.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff we spoke with recognised the importance of people’s dignity and respect.
  • There were arrangements to ensure confidentiality at the reception desk.
  • There were systems in place to ensure that all patient information was stored and kept confidential.
  • The service was registered with the Information Commissioner’s Office (ICO) which is a mandatory requirement for every organisation that processes personal information.
  • The service had a confidentiality policy in place and all staff had signed a confidentiality agreement.
  • All staff had received information governance and general data protection regulation (GDPR) training as part of the service’s mandatory training schedule.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 13 June 2019

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 facilities and premises were appropriate for the services being delivered. Patient security had been considered and there was a door buzzer controlled entry system. The entrance to the centre and the waiting room was visible from the reception area.
  • All non-clinical staff wore a corporate uniform and a name badge.
  • The provider understood the needs of their patients and improved services in response to those needs. Consideration had been given to where patients were seen. For  example, midwifery and paediatric services were seen downstairs in a more informal environment with breast feeding and baby changing facilities and a children's play area. Patients had access to refreshments and fruit. 
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. Accessible toilet facilities were available. There was ramp access to the premises and a wheelchair available to assist patients with mobility requirements.

Timely access to the service

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Appointments were available on a pre-bookable basis on Monday to Thursday 8am to 8pm, Friday from 8am to 7pm and Saturday from 9am to 2pm.
  • Patients with the most urgent needs had their care and treatment prioritised. Waiting times, delays and cancellations were minimal and managed appropriately. The service kept patients informed by phone, email and text and rearranged appointments, where necessary.
  • Patients could access the service for information and assistance through their on-line enquiry form via the service website. The service utilised an external telephone support system during peak call periods to ensure all calls were handled in a timely manner.   

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.

  • The service had complaint policy and procedures in place which included timescales for acknowledging and responding to complaints with investigation outcomes. The centre manager was the designated responsible person to handle all complaints.
  • Patient information about how to make a complaint or raise concerns was available in the centre and on their website.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had recorded seven complaints in the last year. We reviewed two and found that they were satisfactorily handled in a timely manner. We saw, from the examples reviewed, that staff treated patients who made complaints compassionately.
  • The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. We saw that some complaints had also been investigated and discussed as incidents, for example around a delay in a pathology result, to prevent any future occurrence.



Updated 13 June 2019

Leadership capacity and capability;

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

  • The clinical director and centre manager we spoke with were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • The centre manager was visible and approachable and worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

Vision and strategy

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

  • The provider prided itself on a highly personalised, caring journey for all its patients.
  • There was a clear vision and set of values. The service developed its vision, values and strategy jointly with staff. For example, the service’s mission ‘embracing service excellence as a habit not an event’ had been collectively agreed at a staff away day. At the time of our inspection the service was about to enhance its mission statement to include ‘with you every step of the way.’
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them. Staff we spoke with gave examples of what the vision and values meant to them and how they upheld these in their day-to-day role.
  • There was a realistic strategy and a business plan to achieve priorities. The provider had recently recruited a business development manager to its team. The provider had a comprehensive Statement of Purpose which it shared with patients on its website.
  • The service monitored its progress against delivery of the strategy and held staff and senior management away days to realign its strategic direction with its development.


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.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • 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 we spoke with 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 appraisal and career development conversations. All staff had received an appraisal in the last year.
  • There was a strong emphasis on the safety and well-being of all staff.

Governance arrangements

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

  • There was a clear staffing structure and staff were aware of their own roles and accountabilities. Staff had lead roles, for example, infection control, complaints and safeguarding.
  • The service had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. Staff we spoke with knew how to access policies and procedures.
  • There was a clear meeting structure which included weekly whole team staff meeting, senior management meetings and clinical educational breakfast 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.
  • There was some evidence of quality improvement, including clinical audit.
  • We saw evidence of regular staff and clinical meetings. Staff had access to regular appraisals and one-to-one meetings. Staff were required to undertake a range of mandatory training.
  • 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.

  • Patient consultations and treatments were recorded on a secure bespoke clinical system.
  • 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.
  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • The service complied with the Data Protection Act 1998 and was registered with the Information Commissioner’s Office (ICO) which is a mandatory requirement for every organisation that processes personal information.
  • All staff had undertaken information governance and general data protection regulation (GDPR) training as part of the service’s mandatory training schedule.
  • The provider submitted data and notifications to external organisations as required.

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 valued feedback from patients and had a system in place to gather feedback from patients on an on-going basis. Feedback on a consumer review website showed that 84% (based on 25 reviews) of patients felt the service was excellent. Patients had commented that they felt the service was efficient, professional, reliable and very friendly. The provider told us that they had observed patient loyalty with the service with 70% of patients returning to the service and 70% of new patients being through word-of-mouth. 
  • The provider actively engaged with staff through one-to-one meetings, whole team meetings, appraisals and annual team away days to enable team building and to set the strategic direction. Staff we spoke felt involved in creating the vision, values and strategy of the centre.
  • The provider held educational meetings and strategic planning dinners with its consultants and GPs working under practising privileges.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement, for example quality improvement included clinical audit.
  • Quality and operational information was used to ensure and improve performance.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The service encouraged and supported their staff to attend internal and external training and role-specific accreditation courses.
  • The service supported improvement and innovation through their process and system. For example, the service was working towards becoming a paperless organisation and had outsourced some administration functions to streamline the front-of-house service.