We carried out an announced comprehensive inspection on 27 November 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.

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.

CQC inspected the service on 27 March 2018 and asked the provider to make improvements regarding management of significant events, medicines and safety alerts, safeguarding arrangements for adults, infection prevention and control arrangements, training provided for staff, safety and suitability of contract staff, written consent for procedures, and review of policies and procedures. We checked these areas as part of this comprehensive inspection and found they had been resolved.

Mr Yehudi Gordon is an independent provider of medical services in Westminster and treats adults over eighteen years of age for gynaecological ailments.

Twenty patients provided feedback about the service; all were positive about the treatment and care received from the service.

Our key findings were:

• The service had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The service had systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. All staff had received safeguarding training relevant to their role.
• Clinical staff we spoke to were aware if current evidence-based guidelines and they had the skills, knowledge and experience to carry out their roles.
• There was some evidence of quality improvement; however, the service had not undertaken any clinical audits.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Consent procedures were in line with legal requirements.
• Systems were in place to protect personal information about patients.
• Patients could access care and treatment from the centre within an appropriate timescale for their needs.
• The service proactively gathered feedback from patients and staff.
• There was a focus on continuous learning and improvement at all levels of the service.

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

• Review service procedures to consider how they measure improvements in outcomes for patients, for example, through the use of clinical audits.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 27 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 not 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.

The provider offers face to face consultations and examinations for gynaecological ailments, fertility and family planning services for adults over the age of eighteen.

We received sixteen Care Quality Commission comment cards from patients who used the service; all were positive about the service experienced. Many patients reported that the service provided high quality care.

Our key findings were:

• The service had some systems to manage risk; however, the provider did not have a clear system in place to manage significant events, medicines and safety alerts and safeguarding arrangements for adults.
• The provider did not have adequate infection prevention and control arrangements in place.
• The service did not routinely review the effectiveness and appropriateness of the care it provided; however, the patient records we reviewed indicated that care and treatment was delivered according to evidence based guidelines.
• There was limited evidence of quality improvement and clinical audits had not been undertaken.
• Comments cards indicated that staff involved and treated patients with compassion, kindness, dignity and respect.
• The service did not have an accessible toilet suitable for disabled patients.
• Patients reported that they were able to access care when they needed it.
• Information on how to complain was available and easy to understand; however, complaints were not recorded to ensure learning.
• There were some governance arrangements in place; however, there were limited arrangements in place to ensure safe care for patients.

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

• Ensure care and treatment is provided in a safe way for patients.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• 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:

• Put in place adequate procedures to check the safety and suitability of the contract staff used.
• Obtain written consent for appropriate procedures.
• Review service access for patients who are disabled.
• Put in place processes to review policies and procedures regularly.