We carried out an announced comprehensive inspection on 12 December 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.

The service provided circumcisions to those under 18 years of age for cultural and religious reasons under local anaesthetic, and carried out post procedural reviews of patients who had undergone circumcision at the clinic. The service had not been previously inspected by the Care Quality Commission.

The Dr Mohammad Naseem Khan 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.

The service made use of parental feedback as a measure to improve services. They had produced their own survey form and results were analysed on a regular basis. Results obtained in November 2018 from eight parents showed 100% satisfaction with the service.

We also received seven Care Quality Commission comment cards. These were very positive regarding the care delivered by the clinic and mentioned the helpful attitude of staff.

Our key findings were:

• The service was offered on a private, fee paying basis only and was accessible to people who chose to use it.
• Circumcision procedures were safely managed and there were effective levels of patient support and aftercare.
• The service had systems in place to identify, investigate and learn from incidents relating to the safety of patients and staff members.
• There were some systems, processes and practices in place to safeguard patients from abuse, and we saw how these had been used in the past to raise concerns with safeguarding bodies. However, it was noted that two members of non-clinical staff who had no direct contact with patients, parents or carers had not received formal safeguarding training. Since the inspection we have received information and evidence to show that staff had now received this training.
• Information for service users was comprehensive and accessible.
• Patient outcomes were evaluated, analysed and reviewed as part of quality improvement processes. Clinical audits we saw demonstrated the effectiveness of the service.
• Whilst the service had low levels of complaints, we saw evidence that when these were received they had been investigated thoroughly and mechanisms were in place to make subsequent improvements to the service.
• The health and safety risk assessment was limited and lacked depth.
• There was a clear leadership structure, with governance frameworks which supported the delivery of quality care.
• The service encouraged and valued feedback from service users. Comments and feedback for the clinic showed high satisfaction rates.
• Communication between staff was effective with meetings and post sessional debriefings being held.

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

• Review mandatory training needs and ensure staff receive appropriate training as required.
• Review and improve the content and level of depth of the service health and safety risk assessment.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice