We carried out an announced comprehensive inspection on 6 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 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.

This service is registered with CQC under the Health and Social Care Act 2008 to provide the regulated activity of Treatment of Disease, Disorder or Injury. During the inspection, it was determined that the provider was currently providing services which are not regulated by CQC and was not carrying out the regulated activity for which they were registered. There are some exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Universal Medical Centre Limited occupational health services are provided to patients under arrangements made by their employer with whom the service user holds a policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Universal Medical Centre Limited, we were only able to inspect the services which are not arranged for patients by their employers with whom the patient holds a policy (other than a standard health insurance policy).

The Occupational Health Nurse who is also the majority shareholder, director and the sole employee of the organisation 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.

Universal Medical Centre Limited is registered to provide the regulated activity of Treatment of Disease, Disorder or Injury service to adults and children. The Registered Manager told us the service had registered to provide this regulated activity because it planned to employ a GP in order to provide a private consulting doctor service. However at the time of this inspection, the service had not followed through with this plan and had not yet undertaken the regulated activity. The service team consists of an Occupational Health Nurse who is also a registered nurse. There are no other staff employed by the service.

On the day of inspection we collected nine CQC comment cards filled in by people who had used the service under arrangements made by their employer. This information gave us a positive view of the service.

During the inspection we spoke with the director of the organisation. We looked at service policies and procedures and other records about how the service is managed.

Our key findings were:

• The service had arrangements in place for safeguarding which reflected relevant legislation and local requirements.
• The service kept stocks of vaccines on the premises and had systems for monitoring the temperature of the medicine fridge used for storing vaccinations.
• The provider had made arrangements to receive peer support from an occupational health professional who worked in an NHS organisation, although this was an informal arrangement.
• The person delivering the service was conscious of high levels of anxiety and would help to put people at their ease.
• The service had a complaint policy and procedure in place and these were in line with recognised guidance although the service told us they had not received any complaints to date.
• There were effective arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems including during transport.
• The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
• The provider was aware of and complied with the requirements of the duty of candour.

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

• Review current registration arrangements and consider de-registering as a provider if plans to provide a regulated activity are not followed through.
• Consider the timing around when to undertake an audit to prevent and control the risks associated with infection prevention and control and fire safety to ensure these are completed prior to providing services at the registered premises.