We carried out an announced comprehensive inspection on 26 September 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.

As part of our inspection we asked for CQC comment cards to be completed by patients prior to our inspection. We received 39 comment cards all of these were wholly positive about the service experienced. Patients said that staff were accommodating and the treatment provided was of an excellent standard.

Our key findings were:

• The provider had a clear vision to deliver high quality care for patients.
• There were systems and processes in place for taking action and learning lessons from significant events which improved systems in the service. Although all staff were aware of events and there was clear evidence of action taken to make improvements, the service was not recording significant events in line with their policy.
• The service had clearly defined systems, processes and practices to minimise risks to patient safety. Most risks had been assessed and addressed. However, we found that the building managers had yet to implement all of the actions from the latest fire risk assessment.
• Policies and procedures were in place to govern all relevant areas yet the service had not followed its recruitment policy in respect of a self-employed contractor. This individual did not have contact with patients.
• The service had adequate arrangements to respond to emergencies. However not all equipment was being checked regularly to ensure it was operational and, although the service had a supply of emergency medicines, a risk assessment had not been undertaken to ensure that the medicines stocked were sufficient.
• Staff were aware of and used current evidence based guidance relevant to their area of expertise to provide effective care.
• Staff had the skills and knowledge to deliver effective care and treatment.
• There was an effective system in place for obtaining patients’ consent.
• The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management.
• The clinic was aware of and complied with the requirements of the Duty of Candour.

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

• Continue to engage with the building management to ensure any fire risks are addressed.
• Review recruitment and training procedures to ensure that all staff have been subject to proper checks and are adequately trained.
• Review emergency medicines and equipment to ensure that medicines are appropriate and are adequate to respond to risk and that the working status of emergency equipment is regularly checked to ensure that it is fully operational.

Follow the service’s policy for documenting significant events and learning.