We carried out an announced comprehensive inspection on 14 December 2017 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led? We found that this service was not providing effective care in accordance with the relevant regulations. The full comprehensive report for the comprehensive inspection can be found by selecting the ‘all reports’ link for Med-Pol Ltd on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 October 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 14 December 2017.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Med-Pol Ltd is a private medical clinic, which provides services to adults in the following areas: gynaecology and maternity services, surgery, dermatology, urology, and psychiatry. All doctors working in the clinic are Polish and the service is mainly accessed by the Polish community.

This service is registered with CQC under the Health and Social Care Act 2008 to provide the regulated activities of: Diagnostic and screening, Surgical procedures, Family Planning and Treatment of disease, disorder and injury.

Our findings were:

Are services effective?

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

Our key findings were:

• Policy and procedure had been tightened. There was a suite of health and safety policies in place.
• There was evidence of some quality improvement measures that had been initiated since the last inspection to monitor whether medical assessments and treatments are carried out in line with evidence based guidance and standards.
• The practice had reviewed risks associated with the service’s premises and ensured formal safety risk assessments were carried out at regular intervals to reduce risks to patients and staff. There was a policy on legionella. We saw a record of a legionella test carried out by a specialist company. However, there was no record of ongoing monthly temperature checks for legionella. Immediately following our inspection, the service supplied a water temperature measurement log for legionella control.
• The practice had maintained a record of fire drills as outlined in the fire risk assessment.
• The service’s governance arrangements had improved. There was a complaints policy with information on complaints handling. There was no evidence of any record of complaints received in the last twelve months. Staff told us they had not received any complaints. We asked staff about how patients can access information about how to make a complaint. Staff told us that there was information on how to complain on the website. We saw a leaflet about how to complain in the reception area and a complaints and suggestions box on the wall in the waiting area.
• The service told us they had reviewed how patients who are fully reliant on a wheelchair can access the service. The premises are not suitable for wheelchairs. Staff told us that the website had a statement about access which asked patients to mention any mobility needs when making an appointment so that staff can arrange assistance when patients arrive at the building.
• The service had reviewed and updated the business continuity plan to include emergency contact numbers for all staff and local services.

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

• Review policies to ensure staff follow procedure and record legionella checks.
• Continue to develop quality improvement systems that monitor the positive impact on quality of care and patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Med-Pol Medical Centre on 14 December 2017 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 not providing effective care in accordance with the relevant regulations. The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right. We have told the provider to take action (see full details of this action in the Requirement Notice at the end of this report).

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.

Med-Pol Ltd is a private medical clinic, which provides services in the following areas: gynaecology and maternity services, surgery, dermatology, urology and general practice. All doctors working in the clinic are Polish and the service is mainly accessed by the Polish community.

The service is registered with the Care Quality Commission to provide the regulated activities of:

Diagnostic and screening, Surgical procedures, Family Planning and Treatment of disease, disorder and injury.

We received 31 completed comment cards all of which were very positive about the service and indicated that patients were treated with kindness and respect. Staff were described as helpful, caring, thorough and professional.

Our key findings were:

• There was evidence in place to support that the service carried out assessments and treatment in line with relevant and current evidence based guidance and standards.
• Systems were in place to deal with medical emergencies and staff were trained in basic life support.
• The information needed to plan and deliver care and treatment was available to staff in a timely and accessible way.
• There was evidence to demonstrate that the service operated a safe and timely referral process.
• The provider operated safe and effective recruitment procedures to ensure staff were suitable for their role.
• The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring that high quality care was delivered by the service.
• Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
• CQC comment cards completed by patients were very positive about the standard of care they received.
• Systems were in place to protect personal information about patients.
• Although most risks to patients were assessed and monitored, the service had not ensured those associated with legionella were suitably assessed.
• There was no evidence the service undertook any clinical improvement activity such as audit.
• The service had policies and procedures to govern activity, but some of those we reviewed needed updating as they contained out-dated information.
• The service had a complaints policy in place and information about how to make a complaint was available for patients, however we found that complaints were dealt with informally and not in line with the policy.

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

• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

• Review all risks associated with the service’s premises and ensure formal risk assessments are carried out at regular intervals to reduce risks to patients and staff, for example, legionella.
• Review and maintain records of fire drills as outlined in the fire risk assessment.
• Strengthen the service’s governance arrangements, in particular, complaints handling, meetings, practice policies and risk management.
• Review how patients who are fully reliant on a wheelchair can access the service.
• Review and update the business continuity plan to include emergency contact number for all staff.

As part of this inspection we were able to speak with one person who was using the service on the day of our visit. The person told us they were satisfied with the services provided to them. The person told us, "I am very satisfied with the doctor I saw today. She was very kind and explained everything to me. I have nothing to complain about." We also gathered evidence of people’s experiences of the service by reviewing comment cards and the complaints log. We found that people were satisfied with the quality of treatment and services provided.

People experienced care, treatment and support that met their needs and protected their rights.

People were cared for in a clean, hygienic environment.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.