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Inspection Summary


Overall summary & rating

Updated 7 November 2019

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Kings Private Clinic Harrow to rate the service for the provision of safe, effective, caring, responsive and well-led services as part of our current inspection programme.

Kings Private Clinic Harrow provides weight loss services, including prescribed medicines and dietary advice to support weight reduction.

The Clinic Manager 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.

Our key findings were:

  • Patients using this clinic were very happy with the service being provided and gave us positive feedback about the service.
  • The governance arrangements did not ensure that the clinic was providing a high quality service. This was because there was poor management and oversight of prescribing

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.
  • Establish and maintain an appropriate system for the disposal of medicines in accordance with current legislation.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve the prescribing of medicines and only supply unlicensed medicines against valid special clinical needs of an individual patient where there is no suitable licensed medicine available

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

Inspection areas

Safe

Requires improvement

Updated 7 November 2019

We rated safe as

Requires improvement because:

  • Systems and processes did not ensure that care was delivered in a safe way.

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 including locums. 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 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 where required in line with the services policy. (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).

  • 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. We saw that this included carrying out a Legionella Risk Assessment.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions.
  • 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.

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.
  • 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.
  • The registered manager had carried out a risk assessment about the range of emergency medicines and emergency equipment to be kept at the clinic and how these could be accessed.
  • When there were changes to services or staff, the service assessed and monitored the impact on safety.
  • There were appropriate arrangements in place to cover both professional indemnity and public liability.

Information to deliver safe care and treatment

Staff

did not have the information they needed to deliver safe care and treatment to patients.

  • Individual care records were not written 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 not always available to relevant staff in an accessible way. Some of the records that we reviewed showed that patients were prescribed medicines in a way that deviated from the provider’s guidance. Where this happened, the records did not contain information about why the decision was taken to prescribe the medicine in this way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The doctor told us that they did not make use of these systems.
  • 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.

Safe and appropriate use of medicines

The service

did not have reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, controlled drugs, emergency medicines and equipment did not always minimise risks. We found some tablets where the label indicated that they were no longer within their expiry date. These tablets had not been removed or isolated from the tablets ready to be issued to patients. We also found that the service did not have the facility to dispose of these tablets in accordance with current legislation. Following the inspection the provider sent us confirmation that they had put in place procedures for the safe disposal of medicines.
  • The service carried out a medicines review to ensure prescribing was in line with the providers guidelines for safe prescribing. Where issues were identified through these audits there was no record of any action taken.
  • Staff did not always prescribe or supply medicines to patients and give advice on medicines in line with legal requirements and current national guidance. We saw that there were occasions where patients had been commenced on medicines where their Body Mass Index was lower than indicated in the provider’s policy. Where a different approach was taken from the provider’s policy a clear rationale was not recorded. Processes were in place for checking medicines stock and staff kept accurate records of medicines.
  • Some of the medicines this service prescribes for weight loss are unlicensed. Treating patients with unlicensed medicines is higher risk than treating patients with licensed medicines, because unlicensed medicines may not have been assessed for safety, quality and efficacy. These medicines are no longer recommended by the National Institute for Health and Care Excellence (NICE) or the Royal College of Physicians for the treatment of obesity. The British National Formulary states that ‘Drug treatment should never be used as the sole element of treatment (for obesity) and should be used as part of an overall weight management plan’.

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 did not always learn and make 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.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety. The registered manager showed us a log of events that had happened and how the learning from these events had been shared with the staff at the clinic.
  • 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 acted on and learned from events at the provider’s other clinics but did not have a system to receive and act on patient and medicine safety alerts. This meant the service did not have an effective mechanism in place to disseminate these alerts to all members of the team including sessional and agency staff.  Following the inspection the provider sent us a copy of their new procedure to distribute and action these safety alerts.

Effective

Requires improvement

Updated 7 November 2019

We rated effective as

Requires improvement

because:

  • Patients’ needs were not effectively assessed and care and treatment was not provided in line with current legislation, standards and the provider’s guidance.

Effective needs assessment, care and treatment

The provider did not have systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians did not assess needs and did not always deliver care and treatment in line with the provider’s guidance.

  • Patients’ immediate and ongoing needs were not fully assessed. We saw that the records did not always include target weights for patients, although we were told that this was discussed with patients. We also saw that not all entries made on the patient medical record were dated.

  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service was not actively involved in quality improvement activity.

  • The service did not use information about care and treatment to make improvements. The registered manager showed us monitoring audits that were completed monthly, however no actions were recorded to show that the clinic had learned and improved from these. Clinical audit did not have a positive impact on quality of care and outcomes for patients. The audits shown to us only covered a single cycle with no second audit completed.

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.
  • Relevant professionals (medical) were registered with the General Medical Council (GMC) 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.

Coordinating patient care and information sharing

Staff worked together, but did not always work well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care.
  • Before providing treatment, doctors at the service did not always ensure they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • All patients were only asked on initial registration for consent to share details of their consultation and any medicines prescribed with their registered GP. We did not see any evidence that patients were asked to update this on each occasion they used the service.
  • Where patients agreed to share their information, we saw evidence of letters sent by the registered manager to the patients registered GP in line with GMC guidance. When a patient did not agree to share their information, the registered manager told us that the clinic provided a letter for the patient to take to their GP.

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. The registered manager showed us examples of dietary and lifestyle information sheets that were given to patients.
  • 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 partially 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.
  • The service did not record that the doctor had explained to the patient about the use of unlicensed medicines and the implications of doing this. A notice was on display in the clinic to inform patients about the use of unlicensed medicines.  Following the inspection the provider sent us a copy of a revised form that they have now implemented for all patients.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 7 November 2019

We rated caring as

Good

because:

  • The feedback from patients was consistently positive about the service they received.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received.
  • Feedback from patients was positive about the way staff treat 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 were not fluent in English. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Information leaflets were available in easy read formats and other languages to help patients be involved in decisions about their care.
  • Patients we spoke to told us, that they felt listened to and supported by staff. They also felt they had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • 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.

Responsive

Good

Updated 7 November 2019

We rated responsive as

Good

because:

  • The provider organised and delivered the service to meet patients’ needs in a timely way.

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 facilities and premises were appropriate for the services delivered. The clinic was on the ground floor and patients with mobility issues were referred from the provider’s other clinics.
  • Reasonable adjustments had been made to promote equal access to the service. The provider had produced notices in large font. Page magnifiers were available if needed and a portable hearing loop was available.

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, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that they appreciated the walk-in service provided. Patients also told us that they would sometimes ring in advance to check how busy the service was.

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 treated patients who made complaints compassionately.
  • The service had information for patients of any further action that may be available to them should they not be satisfied with the response to their complaint. However, this was not on display in the clinic but available on request.
  • The service had complaint policy and procedures in place. The registered manager showed us that they had not received any complaints since our last inspection.
  • The registered manager showed that they asked a random sample of patients to complete a feedback form each month. These completed forms were looked at and summarised within the clinic but there was nothing to show that any action had been taken as a result of the feedback.

Well-led

Inadequate

Updated 7 November 2019

We rated well-led as

Inadequate because:

The leadership of the service did not effectively drive the delivery of a high-quality service.

Leadership capacity and capability;

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

  • Leaders were knowledgeable about some of the 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. The registered manager was able to show that the provider held briefing meetings and representatives of the provider visited the clinic.

  • 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. The service had a realistic strategy and supporting business plans to achieve priorities.

  • The service developed its vision, values and strategy jointly with staff.

  • 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.

Culture

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.

  • 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. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team.

  • There was an emphasis on the safety and well-being of all staff.

  • There were positive relationships between staff and teams.

Governance arrangements

There were

no

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

  • Structures, processes and systems to support good governance and management were not clearly set out, understood and effective. At this inspection we found that the monitoring of patient records did not effectively identify where these were not being completed correctly or where information was missing. The records lacked target weights, rationale for prescribing outside of the provider’s policy, and the date of when information on the record card had been updated or added to. The monitoring carried out by the registered manager had not identified ways of improving the completion of these patient records.  Following the inspection the provider has sent us copies of revised audit procedures which they are implementing.

  • Staff were clear on their roles and accountabilities.

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.However we found that these were not always operating as intended and the provider had no clear oversight of how the service was following these.

Managing risks, issues and performance

There was no clarity around processes for managing risks, issues and performance.

  • There was not an effective process to identify, understand, monitor and address current and future risks including risks to patient safety. The monitoring of patient records had not identified and corrected the shortfalls in the record keeping process.
  • The service did not have processes to manage current and future performance. Performance of clinical staff could not be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of incidents, and complaints but there was no process in place to manage the oversight of safety alerts.  Following the inspection the provider sent a copy of revised procedure for the sharing and implementing of safety alerts.

Appropriate and accurate information

The service did not act on appropriate and accurate information.

  • The information used to monitor performance and the delivery of quality care was not always accurate and useful. The registered manager had identified weaknesses, but was not aware of how the provider planned to address these or improve performance.

  • 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.

Engagement with patients, the public, staff and external partners

The service involved patients and staff to support sustainable services.

  • The service encouraged and heard views and concerns from patients and staff and acted on them to shape services and culture. The registered manager showed us that they asked for a random sample of patients to complete service feedback questionnaires on a monthly basis. The results of these monthly surveys were discussed at staff meetings, but no collated response was maintained to show progress.

  • Staff could describe to us the systems in place to give feedback. The minutes of staff meetings showed that staff were able to feedback suggestions and how these were followed up.
  • The service was transparent, collaborative and open with stakeholders about performance.