Somerset Menopause Clinic Also known as Mrs Teresa Elisabeth Davison

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 Somerset Menopause Clinic as part of our current inspection programme.

The service registered with CQC under the Health and Social Care Act 2008 on 22 June 2020 and this is the first inspection since registration.

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. Somerset Menopause Clinic provides support and lifestyle advice to women regarding menopause which is not within CQC scope of registration. Therefore, we did not inspect or report on these services. Services offered which are in scope of registration include an initial consultation and assessment to identify an discuss symptoms and concerns, impact on the woman’s life, advice and options for treatment and access to information. The provider is able to discuss and if required, prescribe hormone replacement therapy for the individual.

Our key findings were:

• Care was provided in a way which kept patients safe and protected them from avoidable harm and safeguarded from abuse. The provider had a system for reporting, recording and learning from any significant events.
• The provider had taken precautions to reduce the risk to patients during the COVID-19 pandemic and on return to service delivery. However, the infection prevention and control policy and procedure did not detail these measures.
• The provider did not hold medicines. Prescriptions were stored securely, and the provider had implemented a system so they could track and audit all prescriptions provided to patients.
• Patients received effective care and treatment which met their needs. The provider followed national best practice guidelines and ensured care and treatment was evidenced based.
• The provider delivered a non-judgemental service and communicated well with patients. However, they had not made arrangements to provide support to patients whose first language was not English.
• The provider managed the service in a way which delivered high quality person centred care and treatment.
• Patients did not have access to the complaints procedure or information on how to make a complaint.

The areas where the provider should make improvements are:

• Review and develop the infection prevention and control policy and procedure to detail the actions taken to promote the control of infection from COVID-19.
• Provide clear and accessible information for patients on how to make a complaint should they need to do so.
• Develop systems to support patients whose first language is not English.
• The service had expanded but there was not a formal strategy and supporting business plan to continue the development of the service in line with the increasing demand.

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