The Care Quality Commission
  • Doctor
  • Independent doctor

My Specialist GP

Overall: Good read more about inspection ratings

The Marlow Clinic, Crown House, Crown Road, Marlow, Buckinghamshire, SL7 2QG (01628) 478036

Provided and run by:
Private Specialist GPS Ltd

All Inspections

31 May 2023

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection March 2022)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services well-led? – Good

We carried out an announced focused inspection on 31 May 2023, for My Specialist GP to follow up on breaches of regulations. The key questions we inspected were, are services safe; are services effective; and are services well-led?

We inspected the service on 30 March 2022 and asked the service to make improvements regarding safety and good governance:

  • We issued a Requirement Notice to the My Specialist GP for failing to comply with Regulation 12, (1), Safe care and treatment, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this follow up inspection in May 2023, we found the service had made some improvements, but we identified new concerns which demonstrated a continued breach of this regulation.
  • We issued a Requirement Notice to the My Specialist GP for failing to comply with Regulation 17, Good governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this follow up inspection in May 2023, we found the service was compliant with this regulation

My Specialist GP offers private GP services including consultations, tests, swabs and vaccinations. The service supports patients in the following specialist areas: men’s health, women’s health, paediatrics, ultrasound scanning, joints and injuries, sexual health, minor surgery including cyst, wart and lipoma removal, mental health, cardiology, skin problems, ophthalmology and nutrition. The service also offers other non-regulated aesthetic treatments.

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. My Specialist GP provides a range of non-surgical cosmetic interventions, therefore, we did not inspect or report on these services.

My Specialist GP is registered with the CQC to provide the following regulated activities: Treatment of disease, disorder or injury, Diagnostic and screening procedures, Surgical procedures, Family planning and Maternity and midwifery services. The managing 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 completed appropriate training in line with the provider’s own policy.
  • An induction process was in place for all new clinical and non-clinical staff.
  • Staff had the skills, knowledge, experience, and training to provide an effective service. However, the service did not have safeguards and a system in place to ensure care and treatment was safe to continue when the patient did not consent for their information to be shared with their NHS GP.
  • There was effective and open communication and information sharing amongst the staff team.
  • There were regular team meetings and staff felt motivated to contribute to driving improvement within the service.
  • Clinicians were qualified and experienced in the areas of care they provided.
  • There were appropriate arrangements to manage medical emergencies and suitable emergency medicines and equipment in place.
  • Policies provided up to date, relevant and sufficient information, to provide effective guidance to staff.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients (refer to requirement notice at the end of the report for more detail).

In addition to the above, the areas where the provider should:

  • Implement an effective system for monitoring and recording the fridge temperature in line with own policy.
  • Implement an effective system to ensure that governance and quality assurance processes were effective and individual GP’s work is monitored and audited through a review of their consultations.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

30 March 2021

During a routine inspection

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at My Specialist GP between 29 and 30 March 2022. The inspection was carried out to check whether the service was meeting the legal requirements and regulations associated with the the Health and Social Care Act 2008. This was the first inspection of the service since it registered with the Care Quality Commission (CQC).

My Specialist GP offers private GP services including consultations, tests, swabs and vaccinations. The service supports patients in the following specialist areas: men’s health, women’s health, paediatrics, ultrasound scanning, joints and injuries, sexual health, minor surgery including cyst, wart and lipoma removal, mental health, cardiology, skin problems, ophthalmology and nutrition. The service also offers other non-regulated aesthetic treatments.

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. My Specialist GP provides a range of non-surgical cosmetic interventions, for example acne scarring treatment, skin peels, micro needling and fat freezing which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

My Specialist GP is registered with the CQC to provide the following regulated activities: Treatment of disease, disorder or injury, Diagnostic and screening procedures, Surgical procedures, Family planning and, Maternity and midwifery services.

The managing 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:

  • The premises were clean, well-organised and well-maintained.
  • All staff were up to date with mandatory training.
  • The service had systems for monitoring, detecting and preventing the risk of infection.
  • The service held emergency medicines in line with national guidance and equipment to deal with a medical emergency. However, the service did not have a paediatric pulse oximeter on site.
  • The provider carried out staff recruitment checks in accordance with regulations. However, they did not hold complete records of immunisations in line with current national guidance.
  • Clinical records were clearly written and accurate, and, appropriate advice and guidance was given to patients. However, we did not see evidence of discussions with patients about the potential risks of treatment in the records.
  • The service had a clinical system to store patients’ medical records securely and maintain privacy of confidential information. However, clinicians were required to take photographs using their own personal devices.
  • The service employed clinicians with special interests which allowed them to offer a range of services and treatments and, reduced the number of referrals for patients.
  • The service had a programme of clinical audits which had a positive impact on the quality of care and outcomes for patients.
  • The service asked for details of patients’ NHS GP, but did not always update them about the care and treatment provided.
  • Best practice guidance was followed when providing treatment to patients’.
  • The service monitored patient feedback and adapted services to meet the needs of the patient group.
  • The service had a clear set of values which were patient-centred.
  • Staff were kind, caring and compassionate when treating patients’.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the governance arrangements for monitoring infection prevention and control processes.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care