We carried out an announced comprehensive inspection on 19 April 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 practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The Green Lanes Clinic provides a faith-based circumcision service for all age groups, including adults in the predominantly Turkish and Albanian community. The patients seen at the practice for circumcision are often seen for single treatments and no patient list is kept for these. The clinic also provides a private GP service for those from the community who preferred to see a private GP rather than their NHS GP and those who found it difficult to access NHS services.

The practice principal 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.

Fourteen people provided positive feedback about the service.

Our key findings were:

• The service had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service had system to learn from them and improve.
• There were arrangements in place to check the identity of patients. This included a check on parental responsibility for children who attended for procedures. The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Services were provided to meet the needs of patients.
• Patient feedback for the services offered was consistently positive.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.

There were areas where the provider could make improvements and should

• To review and formalise the system around the identification of patients.
• To review antimicrobial prescribing.

At the last inspection, we found that infection control measures were not robust. We saw hand hygiene recommendations were not always followed through in practice and detergents used to clean instruments was not appropriate. Audits of practice were not routinely undertaken and actioned. We also found that staff in the practice had not received regular training. Since the inspection, the provider submitted an action plan to us to address these areas.

At this inspection we found that effective systems to reduce the risk and spread of infection were now in place. The doctor described the entire process of decontaminating instruments and this was in line with the provider's policy. A comprehensive audit of the practice infection control procedures had been undertaken and actioned in December 2013.

Staff had undergone safeguarding, infection control and relevant life support training since the last inspection. These findings show that the service taken steps to protect people from the risk of unsafe care.

On the day of the inspection, four children were booked in for treatment and one child attended for an assessment, during the morning session. The clinic was staffed by a single handed doctor who carried out the operations and was also the registered manager and owner of the service, an assistant and a part time housekeeper.

People we spoke with were positive about the service. We spoke to family members and responsible guardians of four children who used the service. One family member said “I’m very happy and satisfied with the service." We found evidence that children's guardians discussed risks and benefits of the procedure with the doctor during a consultation appointment, prior to the day of treatment. Consent forms were signed in the doctors office, shortly before the procedure commenced. One family member said, “The doctor and assistant went through the form with us to make sure we understood.”

People told us the doctor asked about the children's medical history. The service took religious and cultural needs into account. Relatives told us staff helped reassure them and their children if they were anxious. One said, “My son was so calm because the doctor distracted him so well.” There were arrangements in place to deal with foreseeable emergencies.

Most relatives told us they were happy with the staff. Relatives told us they had been asked whether they were satisfied with the procedure. Systems were in place and actively used to monitor and improve the quality of the service.

We found some concerns about the cleanliness of the practice and we were also concerned that training needs were not addressed.

We spoke with staff and we viewed notes for patients.We reviewed staff files and equipment maintenance records and policies.We did not speak to patients as there were no appointments booked.

Patient’s complaints were fully investigated and resolved, where possible, to their satisfaction.We spoke with staff and we viewed notes for those patient’s who use services. We reviewed staff files and equipment maintenance records and policies.

We reviewed consent forms signed by patients. We were told by staff that these forms were signed before patients received any care and treatment. We were told that care and treatment were delivered according to those who use services' wishes.

We viewed 30 satisfaction surveys that were completed in 2012 by patients. All satisfaction surveys confirmed that the needs of patients were assessed and treatment was planned and delivered in line with their individual care. We saw documents that showed that there were arrangements in place to deal with foreseeable emergencies.

Patient’s were protected from unsafe or unsuitable equipment as the provider had equipment that was fit for purpose and properly maintained.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. The provider had an accurate record with appropriate information about the care and treatment provided to patients.