This service is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at London Gynaecology at Austin Friars as part of our inspection programme. The provider, London Gynaecology Limited registered with the CQC in April 2020 and began operating The London Gynaecology at Austin Friars in February 2021. This was the services first CQC inspection.
One of the service’s directors 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 70 patient feedback forms. All the feedback indicated that patients were treated with kindness and respect. Staff were described as friendly, caring and professional. In addition, comment cards described the environment as pleasant, clean and tidy.
Our key findings were:
- The provider had clear systems to keep people safe and safeguarded from abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
- Staff assessed patients’ needs and delivered care in line with relevant and current evidence based guidance and standards.
- Patients were treated with dignity and respect and they were involved in decisions about their care and treatment and appropriate medical records were maintained.
- Systems were in place to protect patients’ personal information.
- Information about services and how to complain was available and easy to understand.
- An induction programme was in place for all staff and evidence of certificate of specialist training was maintained for consultants.
- Staff had the skills, knowledge and experience to deliver effective care and treatment.
- The provider had a clear vision to provide a safe and high-quality service and there was a clear leadership and staff structure. Staff understood their roles and responsibilities.
- We saw that there was a system for managing significant events and that learning and improvement was encouraged.
- Staff and patients had access to all standard operating procedures and policies.
- The provider had taken steps to implement quality improvement activity but there were areas for improvement identified. Namely, the provider had not sufficiently monitored the activity carried out by the consultants to ensure they were following clinical guidance.
- The provider did not have effective safeguards in place to ensure only persons 18 years old or above accessed services.
The areas where the provider should make improvements are:
- Develop a comprehensive program of quality improvement including clinical audit to drive improvement in care and treatment outcomes.
- Update the service’s prescribing policy to include medication which should not be prescribed.
- Include third stage process for independent resolution of complaints to the service’s patient information leaflet.
- Include safety alerts as a standing item to the clinical meeting agenda.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care