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Private GP Clinic, Sunningdale Good

Inspection Summary

Overall summary & rating


Updated 28 February 2020

We carried out an announced comprehensive inspection at Private GP Clinic, Sunningdale on 22 January 2020 as part of our inspection programme. This was the first inspection of this service following registration with the CQC in January 2019.

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 and

of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Private GP Clinic, Sunningdale provides a range of non-surgical cosmetic interventions, for example dermal fillers and laser hair removal which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The 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.

We received seven CQC comment cards from patients of the service. They described the service as professional and caring with friendly staff. We did not have the opportunity to speak with any patients on the day of the inspection.

Our key findings from the January 2020 inspection were:

  • Safety processes were established and embedded. Staff knew their role and responsibility towards safeguarding and how to keep patients safe.
  • Medicines used within the building (including emergency medicines and vaccines) were stored in line with guidance and checked appropriately.
  • The provider reviewed and monitored care and treatment to ensure it was providing effective services.
  • Clinical and prescribing audits were used to improve quality. Staff received training appropriate to their role.
  • Patient feedback was positive about their care and treatment. Staff understood how to help and support patients, to meet their needs.
  • The practice was responsive to the needs of their patients and organised care and treatment for the individual. Where the service was not appropriate or could not meet a patients’ needs, they were signposted to an alternative service.
  • Leaders and managers had positive working relationships with their staff and patients. The service had clear policies and procedures which were easily accessible to staff.
  • There was appropriate knowledge and oversight of performance, incidents and events.

Whilst there were no breaches of regulation, the areas the provider should make improvements are:

  • Include explanation documentation in staff recruitment files where employment gaps have been identified and reviewed.
  • Inform staff to correctly label clinical waste when preparing it for collection.
  • Undertake records audits to ensure record keeping and clinical notes are in line with GMC guidance.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 28 February 2020

Safety processes were established and embedded. Staff knew their role and responsibility towards safeguarding and how to keep patients safe. Medicines used within the building (including emergency medicines and vaccines) were stored in line with guidance and checked appropriately.

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis, where appropriate. Disclosure and Barring Service (DBS) checks were undertaken for all staff. (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).

  • We reviewed four staff files and found they all contained details of background checks, including references and clarification of identity. All the files contained a CV which showed the dates and details of previous employment. We noted three of the CVs had gaps in employment detailed on them. The provider was aware of these gaps and the reasons they occurred (such as taking time away from employment to raise children) but had not documented this in the staff files.
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control, including meeting the requirements for reducing the risk of legionella. (Legionella is a specific bacterium found in water supplies, which if undetected can cause ill health or death).
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions.
  • There were systems for safely managing healthcare waste. Clinical waste awaiting removal from the premises was stored in a locked bin away from clinical areas. The bin contained clinical waste bags and a sharps bin that had been closed and secured appropriately, although there were no details of the provider on them for audit trail purposes. (When healthcare services dispose of clinical waste, an audit trail should be observed so the waste company and service provider can identify any problems or concerns with the waste collection at any stage of the process and raise it with the appropriate service). The building was shared with other healthcare practitioners who were not associated with the provider. These practitioners also used the locked storage bin for their healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. For example, the service had a clinical room on the ground floor for patients who could not access the first floor consultation rooms by the stairs.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed. The provider also had another location where patients could access care and treatment, if there was limited or no availability at the Sunningdale clinic. There was no nursing service available at the Sunningdale site and staff could offer an appointment at the other site if this was required.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. All staff had received up to date basic life support and sepsis training.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. We saw a provider risk assessment had been undertaken to determine which emergency medicines to stock for their needs. (If items recommended in national guidance are not kept, a provider should risk assess this to inform their decision).
  • The emergency medicines and equipment was stored on a wheeled trolley with a single drawer access to the medicines. The trolley was stored on the first floor and could not be easily moved to the ground floor if required. The service saw the majority of their patients in the first floor clinical room, but had not considered access to the emergency trolley in the event an incident or emergency occurred on the ground floor. After the inspection, the provider told us they had moved all the medicines and equipment into a grab bag which was easier to manoeuvre.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity and professional indemnity arrangements in place

Information to deliver safe care and treatment



the information they needed to deliver safe care and treatment to patients.

  • Individual care records were held and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way. However, a few of the records we saw did not contain all the required information regarding clinical decision making processes, including relevant background or pre-existing medical history. Records should be written in line with General Medical Council (GMC) guidance. The lead GP told us they would commence undertaking records audits after the inspection.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a 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.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. We saw an example where a patient was referred to an NHS service for urgent review of their presenting symptoms.

Safe and appropriate use of medicines

The service


reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service used private prescriptions which were generated from a template on the computer system and printed at the time of the consultation.
  • The service carried out regular medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • The service prescribed controlled drugs when appropriate and monitored the prescribing of these regularly. (Controlled drugs are a group of medicines including morphine and codeine, which require regular monitoring of their use to reduce the possibility of misuse or abuse).
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • There were effective protocols for verifying the identity of patients including children.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong and to review processes and systems for important and relevant occurrences. For example, the service had a policy to escalate a significant event record if certain conditions or care pathways were utilised such as the two-week referral process.
  • When a significant event was raised and investigated, the service would review if there was any learning identified from it and share lessons appropriately. There had been no significant events, recorded by the service, which had any identified learning. We saw two related to two-week wait processes, which had been made in line with guidance and appropriate follow up actions undertaken. The provider told us they would review all significant events at regular intervals to identify themes and take action to improve safety in the service, where necessary.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.
  • Although there had been no reported unexpected or unintended safety incidents, the service told us they would give affected people reasonable support, truthful information and a verbal and written apology. Records would be kept of any verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including across the two provider sites.



Updated 28 February 2020

The provider reviewed and monitored care and treatment to ensure it was providing effective services. Clinical and prescribing audits were used to improve quality. Staff received training appropriate to their role.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The provider 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 known local guidance.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. For example, audits of repeat prescribing for controlled drugs assessed whether patients had been appropriately and regularly reviewed and if they had been offered advice on the addictive effect of some of these medicines.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

The service used information about care and treatment to make improvements.

  • We were shown an audit of pathology results, which showed all the notes reviewed (a random sample of records covering a six month period) had a record of the result received, had a record of being checked by a GP and details of the follow up noted. A repeat audit was scheduled to ensure these standards were being maintained.

The service made improvements through the use of completed audits. Clinical audit had a positive

impact on quality of care and outcomes for patients. There was clear evidence of action to resolve

concerns and improve quality.

  • The provider had undertaken regular prescribing audits to ensure guidance was being followed. All the audits we saw had identified that prescribing was carried out in line with national guidance. Learning outcomes included offering an advice leaflet to all patients receiving a prescription for antibiotics, to follow up with patients who had been prescribed anti-depressant medicines and a reminder to GPs to record blood pressure when relevant.
  • One of the GPs provided a menopause clinic and had asked patients to complete a health questionnaire. The responses showed interventions had led to an improvement in mood, overall wellbeing, physical symptoms and regulation of their vasomotor symptoms (such as night sweats, hot flashes and flushes) at the time of their follow up appointment.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • GPs were registered with the General Medical Council (GMC), were on the GMC performers list and were up to date with revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The GPs carried out immunisations and vaccinations as there were no nurse clinics at the location. They demonstrated how they stayed up to date with the latest immunisation and vaccination guidance and information.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. We saw referral records and appropriate follow up processes.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment. For example, patients requiring a referral into NHS services required an NHS number. If a patient did not have an NHS number, they were advised to register as a temporary patient with a local NHS GP service.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services, where necessary.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate, highlighted to their normal care provider for additional support. The service told us they could refer patients to NHS services, such as smoking cessation services.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.



Updated 28 February 2020

Patient feedback was positive about their care and treatment. Staff understood how to help and support patients, to meet their needs.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received. A patient survey undertaken in November 2019 showed patients felt the staff were helpful, GP advice was clear, they had been listened to and the GPs had understood their concerns.
  • Feedback to the CQC via the seven patient comment cards was positive about the way staff treated people.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • 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 28 February 2020

The service was responsive to the needs of their patients and organised care and treatment for the individual. Where the service was not appropriate or could not meet a patient’s needs, they were signposted to an alternative service.

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 provider understood the needs of their patients and improved services in response to those needs. The provider had noted an increased use of their other service from patients in the Sunningdale area and had opened this location to meet that demand.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. Patients were asked if they required any support or assistance at the time of booking, so necessary arrangements could be made ahead of the appointment, such as translation services or mobility issues.
  • Service fees were available on the service website and were discussed with patients before they commenced an appointment.

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.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was quick and easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. For example, we saw an urgent referral was made to an NHS provider when a patient’s symptoms required further investigation.

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.

  • Information about how to make a complaint or raise concerns was available. Staff told us they would treat patients who made complaints compassionately.
  • The service had complaint policy and procedures in place. The policy included offering patients details of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • There had been no complaints received by the service since they had registered with the CQC in January 2019. The policy stated all complaints would be dealt with within a specific timescale, would be investigated appropriately and reviewed to identify any lessons or actions. An analysis of all complaints (including those received verbally) would be periodically reviewed to identify any themes or trends and to improve the quality of care.



Updated 28 February 2020

Leaders and managers had positive relationships with their staff and patients. The service had clear policies and procedures which were easily accessible to staff. There was appropriate knowledge and oversight of performance, incidents and events.

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. Appraisal processes included assessing staff for stress and asking about bullying.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

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

  • There was a clear vision and set of values. These included providing patient focused healthcare services and ensuring staff and patients were treated with dignity, honesty and respect.
  • The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against delivery of the strategy.


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 service proactively reviewed high risk referrals (such as referral under the two-week wait referral process for urgent investigation). This enabled the provider to assess if the correct processes had been followed and to pro-actively identify any issues.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff 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. There was a plan for all staff to receive regular annual appraisals once they were eligible (many staff had been recruited, or had changed role within the last 12 months and were not yet due for a 12 month appraisal).
  • There was a strong emphasis on the safety and well-being of all staff. There was a lone working policy and a lone working risk assessment, including the provision of home visits.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. The clinical director also worked within an NHS GP setting and could bring their skills and knowledge of local issues.
  • Staff were clear on their roles and accountabilities. Staff we spoke with could describe the governance arrangements and who to approach if there was an issue or area of concern.
  • Leaders had established appropriate policies, procedures and activities to ensure safety. However, we found concerns over the accessibility of the emergency medicines and equipment and with clinical waste labelling processes, which had not been identified by the provider. The provider reviewed the issues and made appropriate arrangements to correct these, within a few days of the inspection.

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. The service had reviewed and implemented local NHS guidance to follow if a patient presented with symptoms relating to a recent contagious disease outbreak.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • 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.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored and management and staff were held to account.
  • The service used available information to monitor performance and assess the quality care. During the inspection, we found some concerns relating to the quality of clinical records, as some did not contain pertinent information (such as past medical history, medical examination notes or details of decision making processes) which was not in line with General Medical Council guidance for record keeping. The Clinical lead GP told us they would undertake record keeping audits to monitor this after the inspection.
  • The service submitted data or notifications to external organisations as required.
  • 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. All computer records were backed up daily to an external secure server. There were arrangements in place to retain medical records in the event the provider ceased to trade.

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 heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Results from patient satisfaction surveys were benchmarked against the service’s other location’s feedback. Information from NHS local teams were shared with the service by clinicians who also worked for those NHS services.
  • Staff could describe to us the systems in place to give feedback, such as the service complaints process and online feedback.
  • We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • 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 provider supported holistic care and offered longer appointments as a “one stop shop” for patients requiring more than one issue to be seen.
  • The service was co-located within a building with other healthcare providers, such as a physiotherapist. The service could refer patients to these healthcare services if required.