Archived: 16 Beech Drive

This service is rated as Inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at 16 Beech Drive on 26 June 2019. 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.

16 Beech Drive provides private medical services to patients in the North London area. The service offers medical consultations to patients from a doctor trained in general medicine with a speciality in cardiology.

The doctor 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 feedback from patients who had completed the CQC patient comments cards. We received 11 cards and all the comments were positive about the doctor and the service received. Patients described the service as very good or excellent and the doctor as caring. Patients felt they were treated with dignity and respect, listened to and given the right treatment.

Our key findings were:

• The systems in place to keep people safe and safeguarded from abuse needed strengthening.
• The identity of patients, including children was not always checked. The parental authority of adults accompanying children was not always verified.
• Risk assessments had not been completed and mitigating actions to reduce risk in the clinic had not been identified.
• Concerns were found in relation to health and safety, fire safety and infection prevention and control.
• Medical records were not always stored securely.
• There was no emergency equipment and only some emergency medicines. There were no risk assessments in place for emergency equipment and medicines not held by the service.
• There was no quality improvement activity including clinical audit carried out by the service.
• The provider was carrying out regulated activities that they were not registered for.
• Interpretation services were not available for patients who did not speak English or Polish.
• As the doctor worked alone there was no capacity for a chaperone if requested by the patient.
• There was no information available for patients who may wish to complain and no complaints process in place.
• Governance systems were not well established within the service.

• The provider was flexible in their approach to providing appointments and time for patients. There were no time constraints to the length of appointments.
• The provider made use of an external company to seek the views of patients and fellow healthcare professionals who had contact with the service. All feedback was positive about the service.

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.

I am placing this service in 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 for any key question or overall, 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 remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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