We carried out an announced comprehensive inspection on 4 December 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.

This was the first inspection undertaken at this service.

The provider offered individualised services related to hormone testing and therapy, which accounted for 10% of their clinical activity. Patients were treated with unlicensed compounded medicines. (Compounded medicines are made based on a practitioner’s prescription in which individual ingredients are mixed together in the exact strength and dosage form required to meet a patient's individual needs). They also offered minor surgery procedures and weight loss consultations.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Dr D Sister Limited provides a range of aesthetic procedures, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The doctor 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.

Six people provided feedback about the service, which was positive about the care and treatment offered by the service. They were satisfied with the standard of care received and thought the doctor was approachable, committed and caring. They said the staff were helpful and treated them with dignity and respect.

Our key findings were:

• Some systems and processes were in place to keep patients safe. However, we identified some shortfalls in relation to the clinical equipment not being calibrated, safety alerts not received systematically and information shared by email was not password protected in order to ensure data security.
• There was a lack of good governance and limited evidence of quality improvement activity to review the effectiveness and appropriateness of the care provided.
• There was limited information available in the consultation notes, which were stored securely on a cloud-based server.
• Prescription records were stored on a portable external hard drive which was password protected. However, there was a risk of losing prescription records if the hard drive got corrupted, lost or stolen because a data backup arrangement was not in place.
• There was inconsistency in implementing and recording the consent procedures.
• Most of the policies did not include sufficient information.

• The service was unable to provide documentary evidence to demonstrate that all staff had received formal training relevant to their role. A non-clinical member of staff did not receive any formal appraisal within the last 12 months.

• Assessments of patient’s potential conditions were thorough and followed national guidance.
• Appointments were available on a pre-bookable basis. The service provided only face to face consultations.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Information about services and how to complain was available.
• The provider was aware of and complied with the requirements of the Duty of Candour.

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.
• 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.

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:

• Consider arranging a translation service and review the information available for patients who do not speak English.
• Consider how to improve access for patients with hearing difficulties.
• Review the contents of the service’s website and include information about the risks associated with the use of an unlicensed medicine.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice