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Inspection Summary


Overall summary & rating

Updated 12 April 2018

We carried out an announced comprehensive inspection on 8 February 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 not always 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.

Background

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.

This service was inspected in 2013 under our previous inspection regime and it was found at that time to be meeting all the essential standards of care.

The Women’s Wellness Centre is the clinical location of the provider Obsgyncare Ltd and located in Chelsea at 274 Fulham Road, London SW10 9EW. The service is a consultant-led private provider of integrated healthcare for women and children. The service also includes private GP services.

The day-to-day running of the service is provided by the centre manager with support of a business manager and finance manager. The provider employs two ultrasonographers, three healthcare assistants and three receptionists/administration staff. The service is overseen by the organisation’s three board members, of which the centre’s clinical director is the CEO. There are approximately 13 consultants who work under practising privileges (the granting of practising privileges is a well-established process within independent healthcare whereby a medical practitioner is granted permission to work in an independent hospital or clinic, in independent private practice, or within the provision of community services). All consultants hold NHS substantive positions in obstetrics and gynaecology, foetal medicine or paediatrics. The consultants source their own patients and also see patients who book directly with the service. They provide treatment and care with the support of the provider’s ultrasonography, midwife and healthcare assistant team. The service also has three GPs providing regular sessions.

Services provided include antenatal and postnatal care, gynaecology, including vaginal laser treatment, immunisations, sexual health and ultrasound scanning, including 3D and 4D baby ‘keepsake scans’ and GP services. The service also provide a range of complementary therapies, for example, physiotherapy and acupuncture. Complementary services are not regulated by CQC and were not inspected.

The service offers pre-bookable face-to-face appointments to both adults and children. Patients can access appointments Monday to Thursday from 8am to 8pm, Friday from 8am to 7pm and Saturday from 9am to 2pm. At the time of our inspection the service was seeing approximately ten thousand patients per annum.

The provider is registered with the Care Quality Commission (CQC) for the regulated activities of Treatment of Disease Disorder or Injury, Diagnostic & Screening Procedures, Maternity and Midwifery Services and Family Planning.

The centre manager 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.

As part of our inspection, we asked for CQC comments cards to be completed by patients prior to our inspection. Thirty-four comments cards were completed, all of which were positive about the service experienced. Patients commented that the centre offered an excellent service and staff were professional, caring and friendly. We also received five comments through the ‘share your experience’ portal on the CQC website, all of which were positive about the care received. We were unable to speak with any patients directly at the inspection.

Our key findings were:

  • Although there were systems in place to assess, monitor and manage risks to patient safety, we found shortfalls in respect of medicine management and responding to a medical emergency, including access to emergency medicines.
  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
  • The practice carried out staff checks on recruitment, including checks of professional registration where relevant.
  • Staff we spoke with were aware of current evidence based guidance and they had the skills, knowledge and experience to carry out their roles. However, there were no systems in place to monitor that care and treatment was delivered in line with evidence based guidance.
  • There was some quality improvement initiatives which included single cycle audits and reflection on formal patient feedback, but there was no on-going programme of continuous quality improvement.
  • Consent procedures were in place and these were in line with legal requirements.
  • Staff we spoke with were aware of their responsibility to respect people’s diversity and human rights. The service was caring, person centred and compassionate.
  • Systems were in place to protect personal information about patients. The service was registered with the Information Commissioner’s Office (ICO).
  • Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
  • Information about services and how to complain was available.
  • The service had proactively gathered feedback from patients.
  • Governance arrangements were in place. There were clear responsibilities, roles and systems of accountability to support good governance and management.

We identified regulations that were not being met and the provider must:

  • Ensure care and treatment is provided in a safe way to patients.

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

  • Review the process for receiving, disseminating and acting on patient safety alerts.
  • Review infection control processes including the potential need for a formal audit to include clinical waste segregation, staff training requirements and the recording of immunisation status in line with guidance.
  • Review quality improvement initiatives which may include completed clinical audits.
  • Consider arranging formal interpreter and translation services and review the information available for patients who do not speak English.
  • Consider how to improve access to patients with hearing difficulties.
Inspection areas

Safe

Updated 12 April 2018

We found that this service was not providing safe care in accordance with the relevant regulations in respect of medicine management and responding to a medical emergency, including access to emergency medicines.

We have told the provider to take action. You can see full details of this action in the Requirement Notices section at the end of this report.

  • There were systems and processes in place to keep patients safe and safeguarded from abuse and a robust patient identification system was in place.
  • There was a system in place for the reporting and investigation of incidents and significant events. Lessons learnt were shared with staff.
  • There were systems in place to meet health and safety legislation.
  • The provider was aware of and complied with the requirements of the Duty of Candour and encouraged a culture of openness and honesty.

We found areas where improvements should be made relating to the safe provision of treatment. This was because infection control processes including the potential need for a formal audit to include clinical waste segregation, staff training requirements and the recording of immunisation status in line with guidance required review.

Effective

Updated 12 April 2018

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

  • Clinical staff told us they assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines and the British Medical Ultrasound Society (BMUS).
  • Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, we identified gaps for non-clinical staff in infection prevention and control and basic life support.
  • There were formal processes in place to ensure all members of staff received an induction and an appraisal.
  • Consent procedures were in place and these were in line with legal requirements.

We found areas where improvements should be made relating to the effective provision of treatment. This was because the provider did not have systems in place to monitor and ensure care and treatment was delivered in line with evidence based guidance and there was no on-going programme of continuous quality improvement.

Caring

Updated 12 April 2018

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

  • Staff we spoke with were aware of their responsibility to respect people’s diversity and human rights.
  • Systems were in place to ensure that all patient information was stored and kept confidential. The service was registered with the Information Commissioner’s Office (ICO).
  • Patient feedback through CQC comment cards and surveys showed that patients were satisfied with the care and treatment received and that they were treated with dignity and respect.
  • Information for patients about the service was available in a patient brochure and on the centre’s website which included the costs of services provided.

Responsive

Updated 12 April 2018

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

  • Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
  • Access to the service was available for people with mobility needs.
  • There was a complaints procedure in place.

We found areas where improvements should be made relating to the responsive provision of treatment. This was because the provider did not have a hearing loop to aid those patients who were hard of hearing and there was no formal access to interpreter/translation services.

Well-led

Updated 12 April 2018

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

  • There was a clear ethos of patient centred care. Clinical and non-clinical leads had the capacity and skills to deliver high-quality, sustainable care.
  • The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • The service engaged and involved patients and staff to support high-quality sustainable services.