We carried out an announced comprehensive inspection on 24 April 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 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.

Background

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.

Bilan Medic Centre Limited is registered with the Care Quality Commission to provide Diagnostic and Screening procedures and Treatment of Disease, Disorder, Injury (TDDI).

Bilan Medic Centre Limited provides primary healthcare services for primarily for the Somali and East Africa patients living in the West/ North West London area. The service offers private consultations with a female doctor offering gynaecology care. The service only sees patients aged 18 years and over. The service is located in a rented private building on the third floor that can be assessed using a lift. The service has access to a waiting area and a private consultation room. At the time of our inspection the clinic staff comprised of the doctor who is the owner of the business and one administrative staff. On the day of the inspection we meet with the doctor only.

The clinics opening times were Tuesday -Saturday 10:30am-5:30pm.When the clinic was closed there was a recorded message on the answer phone that directed patients to the doctor.

The service undertakes approximately 50 consultations per month.

The cost of the service for patients is advertised on leaflets at the practice and detailed patient consultation forms and prices are also displayed in the clinic.

The service employs an administrator who supports the doctor with general day to day administrative duties.

The doctor is the organisations CQC 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 obtained feedback about the service from eight patient Care Quality Commission comment cards. All feedback we received was positive about the staff and service offered by the clinic.

Our key findings were:

• There was an effective system in place for reporting and recording significant events.
• Risks to patients were always assessed and well managed, including those relating to recruitment checks.
• The clinic had a number of policies and procedures to govern activity.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Information about services and how to complain was available and easy to understand.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• The service proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

• Review the system of recording significant events and complaints.
• Review their safety systems to provide reassurances that the defibrillator in the building is working adequately.
• Develop quality assurance processes to include two cycle clinical audits in order to drive improvement.