The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Westminster Clinic Limited - at 31 Harley St.

Overall: Good read more about inspection ratings

31 Harley Street, London, W1G 9QS (01789) 414203

Provided and run by:
Westminster Clinic Limited

Important: This service is now registered at a different address - see new profile

All Inspections

3 August 2021

During an inspection looking at part of the service

Our rating of this location improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learnt lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on their treatment and supported them to make decisions about their care. Key services were available five days a week.
  • The service planned care to meet the needs of patients, took account of most patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and how to apply this in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and all staff were committed to improving services continually.

However:

  • Some of the clinic’s files still contained some older versions of policies or documents. This meant that some staff may refer to outdated guidance when delivering care.
  • The lead doctor had recently supported another doctor to learn how to undertake hair transplant surgery. A summary document had been introduced to evidence the skills and training of this doctor. However, there was no contemporaneous record of the training or overarching policy or governance in relation to this training.
  • There was no written information available in other languages or formats and staff seemed unsure as to how this would be provided. This meant some patients may not be able to access the service easily.
  • The service had subscribed to a service that provided an independent review of complaints, but the clinic’s complaint policy did not accurately reflect this on the day of inspection. The service sent a refreshed policy containing correct details shortly after our inspection.

18 May 2021

During a routine inspection

We have not rated this service before. We rated it as inadequate because:

  • Not all staff understood how to protect patients from potential abuse. The service did not consistently control infection risk, including the risk of COVID-19 transmission. The design, maintenance and use of facilities, premises and equipment was not consistent. Staff could not evidence they assessed potential risks to patients, and they did not keep detailed records of patients’ care and treatment. The service did not manage patient safety incidents adequately, as we were not assured staff would recognise and report incidents and near misses. There was no evidence of any learned lessons from incidents.
  • The service did not provide care and treatment based on national guidance or evidence-based practice. There was no record of staff assessing or monitoring patients regularly to see if they were in pain. Staff did not fully monitor the effectiveness of care and treatment or use the findings to make improvements and achieve good outcomes for patients.
  • There was no process for people to escalate their complaints or concerns beyond a local level.
  • The registered manager failed to demonstrate an understanding of how compliance with the fundamental standards of care helped to ensure maintenance of quality at the location. The service did not have a formal vision or strategy. The registered manager did not operate an effective governance process throughout the service and did not use systems to manage performance effectively. The clinic lacked a robust approach to quality improvement and made only limited improvements in response to feedback.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills. They managed medicines well.
  • Staff provided gave patients enough to eat and drink. Staff worked well together for the benefit of patients and supported them to make decisions about their care. Services were available five days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided support to patients.
  • The service planned care to meet the needs of patients and took account of some patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

This service is being placed into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.