We carried out an announced comprehensive inspection of Hightree Clinic on 9 October 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This was the providers first comprehensive inspection. We found the service was not providing safe, effective, responsive or well-led care in accordance with the relevant regulations. We issued two warning notices requiring the provider to achieve compliance with the regulations set out in those warning notices. Warning notices were issued against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). We also issued two requirement notices for Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 19 (Fees) of the CQC (Registration) Regulations 2009. We then undertook a focussed inspection on 23 January 2019. At this inspection, we found the requirements of the two warning notices had not all been met. We issued two further warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

This inspection was a focused inspection carried out on 30 April 2019 to confirm whether the provider was compliant with the warning notices issued, following the inspection on 23 January 2019. This report only covers our findings in relation to the requirements set out in the warning notices.

Our findings were:

At this inspection, although significant improvements had been made, we found the requirements of the two warning notices had not all been met.

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 responsive?

We found that this service was not 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.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC, which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Hightree Clinic is an independent doctor service. They provide consultation, treatment and prescribing services for conventional and complementary medicine, with an aim to improve and/or sustain patients’ overall quality of life. The clinic offers consultation and treatment only to patients over the age of 18.

Hightree Clinic provides a range of complementary therapies, for example medical acupuncture and osteopathy, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The lead GP 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 clinic had made significant improvements since our last inspection, although not all requirements had been met. The provider was fully aware of the remaining issues and had realistic action plans to make sure all improvements were made.
• The provider had improved the systems and processes for the recording of patient details, consultation and treatment. These changes were new and not yet embedded. Therefore, we found some gaps in recording in both hard copy and electronic files. The provider was taking appropriate steps to improve record keeping.
• There were processes for managing risks and performance, however these were not always complete or fully implemented. This included; the systems for infection, prevention and control; procedures to minimise the risk of legionella; the recording and oversight of safety alerts.
• There was some evidence of quality improvement. However, we found a lack of clinical audit to monitor quality and to drive improvements.
• Some of the processes to identify, understand, monitor and address current and future risks including risks to patient safety had improved. This included the recording and oversight of significant events and complaints.
• The provider had continued to review and update their policies and procedures. We found not all policies were in place, and some were undated. This was a significant piece of work that was ongoing.
• The provider had strengthened the workforce by employing a nurse and a data management administrator. Staff were clear on their roles and responsibilities at the clinic.
• Staff we spoke with told us it was an open and friendly culture. They felt communication and organisation at the clinic had improved and they felt positive about the improvements.

We identified regulations that were not being met and the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We have told the provider to take action (you can see full details of the action and regulations not being met in the Requirement Notices section at the end of this report).

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection of Hightree Clinic on 9 October 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This was the providers first comprehensive inspection. We found the service was not providing safe, effective, responsive or well-led care in accordance with the relevant regulations. We issued two warning notices requiring the provider to achieve compliance with the regulations set out in those warning notices. A warning notice was issued against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). We also issued two requirement notices for Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 19 (Fees) of the CQC (Registration) Regulations 2009.

This inspection was a focused inspection carried out on 23 January 2019 to confirm whether the provider was compliant with the warning notices issued, following the inspection on 9 October 2018. This report only covers our findings in relation to the requirements set out in the warning notices.

Our findings were:

At this inspection we found that although improvements had been made, the requirements of the two warning notices had not all been met.

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 responsive?

We found that this service was not 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.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC, which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Hightree Clinic is an independent doctor service. They provide consultation, treatment and prescribing services for conventional and complementary medicine, with an aim to improve and/or sustain patients’ overall quality of life. The clinic offers consultation and treatment only to patients over the age of 18.

Hightree Clinic provides a range of complementary therapies, for example medical acupuncture and osteopathy, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The lead GP 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 reviewed and improved some systems and processes at the clinic, but not all requirements had been completed. They had developed an action plan to make sure the concerns identified at our last inspection would be addressed. We saw all actions were planned for completion by March 2019.
• The processes to identify, understand, monitor and address current and future risks including risks to patient safety were not always complete or clearly set out. This included the recording and oversight of safety alerts, significant events and complaints, the systems for monitoring patients’ health and the management of patient records.
• Although the recording of patients’ information, consultations and treatment had been improved, the standard of the files we reviewed was inconsistent and they did not always contain information we would expect to see.
• We saw that the provider had started a process to review and update their policies and procedures to ensure they contained relevant and up to date information. This was not yet complete.
• A variety of risk assessments had been completed in relation to safety issues, including for fire and health and safety. However, an action plan was not in place to ensure required improvements were completed.
• Staff told us the morale had improved at the clinic and they felt more supported. They were aware that improvements were still required and they felt encouraged to be involved in the process.

We identified regulations that were not being met and the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We have told the provider to take action (you can see full details of the action and regulations not being met in the Enforcement Actions section at the end of this report).

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 9 October 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 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 not 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.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC, which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Hightree Clinic is an independent doctor service. They provide consultation, treatment and prescribing services for conventional and complementary medicine, with an aim to improve and/or sustain patients’ overall quality of life. The clinic offers consultation and treatment only to patients over the age of 18.

Hightree Clinic provides a range of complementary therapies, for example medical acupuncture and osteopathy, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The lead GP 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.

We received 12 completed Care Quality Commission comment cards. Feedback from patients was consistently positive. We received comments that the staff were friendly, kind and put them at ease. They commented that the service received was supportive, caring, informative and efficient. Many patients described how they had used the service on several occasions.

Our key findings were:

• The registered manager recognised that the current systems and processes at the clinic needed updating or improvement. They had identified gaps in compliance with regulation and throughout the inspection we recognised some improvements were planned or underway.
• We found that the processes to identify, understand, monitor and address current and future risks including risks to patient safety were not yet well implemented. For example, the recording and oversight of safety alerts, significant events and complaints.
• We found that patients’ medical records were not always clear, comprehensive and legible. We noted that not all records contained information we would expect to see about the consultation and treatment plan. We could not be assured that they always prescribed, administered and supplied medicines to patients in line with legal requirements.
• Risks to patients, staff and visitors to the clinic were not always assessed or well managed. This included; the systems to manage infection prevention and control (IPC), the completion of recruitment checks, and comprehensive risk assessments being carried out in relation to safety issues.
• There was limited evidence of quality improvement activity to review the effectiveness and appropriateness of the care provided. We did not see any clinical audits to monitor the quality of prescribing for instance.
• The facilities and premises were appropriate for the services delivered.
• Feedback from patients was consistently positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• We found that policies and procedures were not all specific to the clinic, regularly reviewed or contained up to date information.
• There was a clear leadership structure and staff felt supported. The clinic proactively sought feedback from staff and patients.

We identified regulations that were not being met and the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• 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.
• Ensure service users, or a person acting on the service user’s behalf, are provided with written information about any fees, contracts and terms and conditions, relating to the cost of their care or treatment.

You can see full details of the regulations not being met at the end of this report.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice