We undertook a comprehensive inspection of 27 Wimpole Street on the 28 March 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found that the service was providing effective, caring, responsive, well led care however, they were not providing safe care in accordance with the relevant regulations.

The full comprehensive report following the inspection on 28 March 2018 can be found by

selecting the ‘all reports’ link for 27 Wimpole Street on our website at www.cqc.org.uk.

We undertook an announced focused inspection of 27 Wimpole Street on the 22 February 2019 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 March 2018, these were;

• There was no health and safety policy.
• Actions from a fire risk assessment had not been completed.
• There was no risk assessment to determine which staff needed infection control training.

This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations

27 Wimpole Street is a private doctor consultation and treatment service. The service offers private consultations with a general physician and a gynaecologist. There are two GPs, one male, one female, a part time nurse and two administrative staff. The service operates five days a week from 27 Wimpole Street, London. The building is owned by the service, however services are only provided on the ground floor. They only provided services for adults.

Dr KJ Ugboma 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.

This service is registered with CQC under the Health and Social Care Act 2008 for the regulated activities of Treatment of disease, disorder or injury and Diagnostic and screening procedures.

We received 33 completed CQC comment cards which were all very positive about the level of service and the care provided, patients felt that they were treated with dignity and respect.

Our key findings were:

• Although we could see that some of the actions from the 2019 fire risk assessment had been completed, the practice could not evidence all actions had been completed.
• The service lead was the lead member of staff for safeguarding and all clinical staff had undertaken adult and child safeguarding training, however non-clinical staff received their training from the safeguarding lead.
• The service had established a health and safety policy and non-clinical staff members had undertaken infection control training.
• The provider was aware of current evidence based guidance and they had the skills, knowledge and experience to carry out his role.
• The provider was aware of their responsibility to respect people’s diversity and human rights.
• Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
• There was a complaints procedure in place and information on how to complain was readily available.
• Governance arrangements were in place. There were clear responsibilities, roles and systems of accountability to support good governance and management.
• The service had systems and processes in place to ensure patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• There was a clear leadership structure and staff felt supported by management.
• The service had systems in place to collect and analyse feedback from patients.

There were areas where the provider could make improvements and should:

• Review the need to establish a cold chain policy with appropriate recording of temperatures.
• Review the 2016 fire risk assessment and ensure that all actions have been completed.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

We carried out an announced comprehensive inspection on 28 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was not providing safe care in accordance with the relevant regulations

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

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.

27 Wimpole Street is a private doctor consultation and treatment service. The service offers private consultations with a general physician and a gynaecologist. There are two GPs, one male, one female, a part time nurse and two administrative staff. The service operates five days a week from 27 Wimpole Street, London. The building is owned by the service, however services are only provided on the ground floor. They provided services for adults and children accompanied by adults.

Dr KJ Ugboma 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.

This service is registered with CQC under the Health and Social Care Act 2008 for the regulated activities of Treatment of disease, disorder or injury and Diagnostic and screening procedures.

We received 33 completed CQC comment cards which were all very positive about the level of service and the care provided, patients felt that they were treated with dignity and respect.

Our key findings were:

• The service lead was the lead member of staff for safeguarding and all clinical staff had undertaken adult and child safeguarding training, however non-clinical staff received their training from the safeguarding lead.
• There was no evidence provided during our inspection to show that action points from a 2016 fire risk assessment had been completed.
• There was no health and safety policy or evidence of staff including non-clinical staff members having infection control training.
• The provider was aware of current evidence based guidance and they had the skills, knowledge and experience to carry out his role.
• The provider was aware of their responsibility to respect people’s diversity and human rights.
• Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
• There was a complaints procedure in place and information on how to complain was readily available.
• Governance arrangements were in place. There were clear responsibilities, roles and systems of accountability to support good governance and management.
• The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• There was a clear leadership structure and staff felt supported by management.
• The service had systems in place to collect and analyse feedback from patients.

We identified regulations that were not being met and the provider must:

• Review the fire risk assessment and ensure all actions have been taken.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

• Review the roles of staff and risk assess whether infection control training is required.
• Review infection control arrangements for the service.

People we spoke with told us they were happy with the care and treatment they received from the doctor.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. On initial consultation the doctor would take a person’s full medical history, carry out an examination of the person and if required investigate a person’s condition further.

The doctor explained that it was difficult to obtain regular feedback from patients. He was designing a patient survey to address this which was now mandatory in line with his annual appraisal.

We saw evidence through a patient satisfaction survey report that people were satisfied with the service, but were unable to speak to any person on this occasion. Feedback from patient satisfaction survey indicated that patients were generally happy with the care they had received. They commented that staff have been supportive, treated them with respect and involved them in their care. The majority of people felt they were kept informed and given enough information to make decisions.