We carried out an announced comprehensive inspection on 12 March 2019 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 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 for immunisations including childhood, travel vaccinations and travel medical advice, and screening services for medical clearance and post-travel consultations.

We received feedback from seventeen patients who used the service which were wholly positive about the service experienced. Many patients reported that the service provided high quality care.

The lead nurse 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.

Our key findings were:

• The service had systems to manage risk so that safety incidents were less likely to happen.
• The service reviewed the appropriateness of the care it provided. However, it did not always ensure that care and treatment is delivered according to evidence based guidelines.
• Staff treated patients with compassion, kindness, dignity and respect.
• Services were provided mostly met the needs of patients.
• Patient feedback for the services offered was consistently positive.
• Responsibilities, roles and systems of accountability to support governance and management required improvement.

There areas the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way for patients.
• 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:

• Review systems in place to assure that an adult accompanying a child had parental authority.
• Review the policy to identify and verify a patient’s identity prior to consultation.
• Review service procedures to ensure staff receive training appropriate to their role.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care