We carried out an announced comprehensive inspection on 3 May 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

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 not 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.

Humanitas Healthcare Services Ltd operates from Blakenall Village Centre, Walsall. The services they provide for both NHS and private patients include:

• Vasectomy
• Carpel tunnel decompression
• Trigger finger release
• Soft tissue and joint injections
• Excision of clinically benign lumps
• Nail surgery

Dr A Benjamin is the registered manager for Humanitas Healthcare Services Ltd. 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 spoke with two patients following the inspection. The feedback demonstrated positive outcomes for patients. Patients spoke highly of the care and treatment they had received from the clinic. They described staff as friendly and caring. They also commented that staff put them at their ease during the procedure. Staff we spoke with told us they were well supported in their work and were proud to be part of a team which provided a good quality service.

Our key findings were:

• Patients received detailed and clear information about their proposed treatment which enabled them to make an informed decision.
• Patients were offered convenient, timely and flexible appointments.
• Staff helped patients be involved in decisions about their care. Patients were provided with written pre and post treatment literature. The provider did not have a written recruitment and selection policy and procedure. They had not obtained the appropriate staff checks in accordance with the regulatory requirements for staff who worked occasionally.
• There was an effective system to manage infection prevention and control (IPC).
• There were limited systems to assess, monitor and manage risks to patient safety. Risk assessments in relation to safety issues for the building and the range of emergency medicines available to staff had not been completed.
• There was a system and procedure for recording and acting on significant events and incidents.
• There were limited processes for managing risks, issues and performance. Health and safety risk assessments had not been completed to identify hazards and mitigate potential risks at the site.
• There was little evidence to support that clinical audit had a positive impact on quality of care and outcomes for patients.
• Information about the range of procedures offered by the provider was not up to date and accurate.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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:

• Implement an effective process to ensure the identification of significant events.
• Review the process for annual appraisals and development plans.
• Review the process used to check the expiry dates of single use items.
• Review and update the consent form to include the recent updates in guidance.
• Update the information about the range of procedures offered by the provider so that accurately reflects what is offered.