We carried out an announced comprehensive inspection on 4 September2018 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 Monteiro Clinic Limited is an independent provider of medical services. The service provides a full range of General Practice services. The service is provided primarily for patients for whom Spanish or Portuguese are their first language who make up 70% of the services list. Services are provided at 2 Clapham Road, Oval, London, SW9 0JG in the London borough of Lambeth. All of the services provided are private and are therefore fee paying, no NHS services are provided at The Monteiro Clinic Limited.

The service is open Monday to Friday from 8:20am to 7pm and Saturday 8:30am to 4pm. The service does not offer elective care outside of these hours, and patients are not specifically directed to other services.

The premise is located on two floors. The property is leased by the provider and the premises consist of a patient reception area, five consulting rooms and a dispensing pharmacy.

The service is operated by a general practitioner who works at the service. The service also employs three nurses, a service manager and four receptionists. There are six other GPs who work at the service but they are not employed by the service, working on a contract basis.

The lead clinician 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. The service is registered with the Care Quality Commission (CQC) to provide the regulated activity of treatment of disease, disorder or injury and diagnostic and screening procedures.

Our key findings were:

• The service had systems in place to manage significant events.
• Medicines were in place to manage some emergencies, but some medicines for use in emergencies were not in place at the time of the inspection. The service did not have a policy to follow a particular medicines formulary.
• Vaccine refrigerators were not systematically temperature checked, and where temperatures were out of the safe range no action was taken. Vaccines were pushed to the back of the refrigerator where they were at risk of frosting, which would impact on the efficacy of the vaccine.
• Policies and procedures were in place to govern all relevant areas, but the service did not have patient group directions in place for the practice nurse. Practice nurses had not been appraised, and the service had not taken steps to ensure that nursing staff were up to date with training specific to their role
• The service had an infection control policy but had not carried out an audit. The rooms and all equipment were clean, but there were no curtains in four of the consulting rooms, and where sharps bins and curtains were in place they were not dated.
• Clinicians assessed patients’ needs and delivered care in line with current evidence based guidance.
• The service had systems in place for monitoring and auditing the care that had been provided.
• Staff had not been trained in areas relevant to their role.
• Patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services was available and easy to understand. The complaints system was clear and was clearly advertised.
• Patients were provided with information relating to their condition and where relevant how to manage their condition at home.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• The clinic sought feedback from patients, which showed that a large majority of patients were satisfied with the service they had received.
• The clinic 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. This should include ensuring systems are in place to assure medicines management, infection control and equipment to manage emergencies and full infection control processes.
• 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. This should include ensuring staff are trained in relevant areas, supervision of the nurses working at the service, and completion of appraisals.

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:

• Review privacy arrangements in clinical rooms.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We inspected the Monteiro Clinic to follow up on issues identified during inspections in October 2014 and December 2014. During the inspection in October 2014 we found that the provider did not always ensure that pre-employment checks were conducted before applicants’ commenced work in the service. There was also a lack of effective monitoring of the service for quality and improvement. During the December 2014 inspection we found that patients’ needs were not being assessed appropriately and patients with long-term conditions were not receiving regular reviews. Medicines were not being dispensed with the appropriate labelling and there was not a suitable policy in place for the management of medicines.

Our inspection in June 2015 found that improvements had been made to the service. All staff employed by the service since out last inspection had the appropriate pre-employment checks carried out to ensure their suitability to work in the service. There were processes in place to monitor the quality of the service. This included clinical audits and staff satisfaction surveys. Patients’ needs were being assessed appropriately and reviews were taking place. Appropriate procedures were in place to manage medicines and medicines were being dispensed appropriately.

We inspected The Monteiro Clinic to follow up on issues identified at during an inspection in June 2014. During the inspection in June 2014 we found that the provider did not always assess patients’ needs appropriately because baseline checks were not always carried out. Care was not always planned to ensure patients welfare and care because patients with long-term conditions did not have reviews of appropriate follow-ups. Medicines were not being dispensed with appropriate labelling and there were no procedures in place to cover safe storage, prescribing, dispensing, administration or disposal of medicines. We did not speak with patients who use the service during our inspection.

Our inspection in December 2014 found that patients' needs were still not being assessed appropriately and the provider had not implemented any of the action set out in their action plan. We found that patients were being referred to specialists at the hospital but doctors were not following up to check the outcomes or contacting patients to discuss the outcomes. Patients with long-term conditions were still not receiving regular reviews.

Medicines were still being dispensed to patients without appropriate labelling of their name, date of supply or directions on how to take them. The provider still did not have an appropriate medicines management procedure. This meant staff did not have guidance to follow to ensure medicines were handled safely.

We visited the clinic following our inspection of 17 February 2014 where they had failed to meet the required standard for safeguarding, staffing issues and monitoring the quality of the service.

During our inspection of 17 October 2014 we found people who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff had received safeguarding training and demonstrated an awareness of safeguarding issues. Processes were in place to report safeguarding concerns to the local authority.

The provider was not carrying out appropriate pre-employment checks on applicants before they were started working at the clinic. References were not always taken and the provider did not obtain satisfactory evidence of conduct in previous employment.

Staff were supported through appropriate opportunities for development. Training was available to all staff and we saw evidence of recent training. There were no processes in place for non-clinical staff to receive regular supervision or appraisals, however, staff told us they felt supported and could go to the manager whenever they needed to.

There continued to be no processes in place to assess and monitor the quality of the service. Incidents were not recorded or monitored and no audits were undertaken to assess the quality or plan improvement. There were no processes to report or learn from incidents.

We inspected The Monteiro Clinic Limited following concerns the Care Quality Commission (CQC) had received about the care and welfare of people and the management of medicines. We did not speak with people who use the service during our inspection.

We found that patient’s needs were not always assessed appropriately because baseline tests such as blood testing or urine samples were not always completed before a diagnosis. Care and treatment was not always planned to ensure the welfare and safety of people with long-term conditions. For example patients with long –term conditions did not receive regular reviews and routine tests such as blood testing as part of the on-going monitoring.

We saw medicines were being dispensed to patients without appropriate labelling of their name, date of supply or directions on how to take them. The provider did not have a medicines management procedure which covered the obtaining, safe storage, prescribing, dispensing, administration and disposal of medicines. This meant staff had no guidance to follow to ensure medicines were handled safely.

Patients who use the service told us that they were happy with their care. One patient told us her opinions and views were taken into account by the doctor. She said “they speak to people really well here. They are really nice and want you to express what is going on”. Another patient told us that he felt involved in his care and that he was respected as an individual.

Patients who use the service told us that their privacy and dignity was maintained and that they had been listened to by staff. All consultations, tests and examinations were carried out in individual consulting or treatment rooms.

Staff were aware of how to raise issues of concern in relation to vulnerable adults and children. However, the clinic did not have a policy available in either of these areas. None of the staff we spoke with had received up-to-date training on vulnerable adults or children.

Staff told us they were supported and that communication was good between members of staff. They felt able to raise any issues of concern if they arose.

We found that patients who were not fluent in English, but were fluent in Spanish or Portuguese, valued the opportunity of speaking about a health issue to a professional who spoke their language. Staff told us they were more successful in communicating recommended changes in diet and lifestyle to patients in their own language.

People told us they liked the service provided at the Monteiro clinic and found the staff “friendly”.

Care and treatment was planned and delivered in line with their individual care plan. Staff checked people’s allergies and past medical history before providing any treatment to ensure people were kept safe.

The practice did not have appropriate arrangements in place to ensure people were protected against the risk of abuse. The service did not have a safeguarding children or vulnerable adults policy and not all staff were familiar with required reporting procedures.

The required checks had not been undertaken before staff began working for the service. There was no evidence of attendance at interview, references had not been obtained and there were limited processes for checking the skills, knowledge and experience of staff.

Staff were not adequately supported. Staff had not received appropriate training or professional development. No appraisals had been undertaken in the last year to review staff’s performance or identify training requirements.

Appropriate monitoring of the quality of the service was not in place. People were given the opportunity to feedback on the service provided and there was a complaint process in place. However, there was no process to report and learn from incidents and no clinical audits had been undertaken.