Just Health Also known as SSYNS LIMITED

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, as part of our inspection programme on 17 May 2022 at Just Health, which is located at 156 Colne Road Burnley Lancashire BB10 1DT.

This was the service’s first CQC inspection.

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. Just Health provides a range of driver medical checks such those required to drive a heavy good vehicle (HGV) or a taxi. The activities undertaken in relation to this type of service are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

Mr Yasir Jaleel is the nominated individual and the registered manager for the provider SSYNS Limited. 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 provider offered a range of different services. Some of which were not within the scope of CQC registration.
• Those services that were within CQC scope were offered on a private, fee-paying basis only and were accessible to patients who chose to use it.
• Services offered at the time of this inspection were hay fever treatments and baby circumcisions. The website for the service provided comprehensive information about these services and included details of fees.
• Specific feedback for the services offered was not proactively requested. However patients had opportunities to post online reviews.
• Circumcision procedures were safely managed and there were effective levels of patient support and post-operative care.
• A risk assessment for the safe movement of the child following the circumcision procedure from the clinical room up a set of stairs to the recovery room was not in place.
• Systems to identify parental identity and obtain written consent for the circumcision service was effective. Written consent was also obtained for the provision of the hay fever treatment.
• The service shared relevant information with a patient’s own GP as appropriate, although patients opted in to, rather than out of sharing information with their GP following the hay fever treatment.
• The staff team was small but team members were aware of their own role and responsibilities and told us they felt supported.
• Staff recruitment records were incomplete. However we received additional recruitment records after the inspection.
• The provider was unable to demonstrate clearly that non clinical staff were trained appropriately. A system to provide an overview of staff training was not in place. There was no evidence available to show that all staff had received training in fire safety, infection prevention and control, and up to date training in safeguarding adults and children. The manager provided certificates of this training for staff. This showed training was undertaken in these areas on the day of the inspection and the day after the inspection. Training in equality and diversity and chaperoning had not been undertaken, however the provider confirmed after the inspection that staff had read policies on these.
• Some policies and procedures were not available, including responding to a medical emergency, a recruitment policy and a business continuity policy. These were provided after the inspection.
• An infection prevention and control (IPC) policy and audit was available. The placement and cleanliness of the sharps bin used for surgical instruments did not comply with IPC good practice standards.
• The service had a quality management statement in place but the inspection identified some areas where the standards identified were not achieved.

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

• 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:

• Amend the medicine monitoring record to reflect the name of the medicine, the stock and expiry date for each medicine.
• Implement a risk assessment to mitigate potential risk of carrying a small child up and down stairs following a surgical procedure.
• Re-word the patient consent form used for the treatment of hay fever so that patients are automatically opted into notifying their GP of this treatment.
• Develop formal systems to obtain patient feedback regarding the provision of regulated activities to inform the quality of the services provided.

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