We carried out an announced comprehensive inspection on 19 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 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 provides independent non-NHS patient fee paid private primary care within an independent non-NHS private hospital setting.

A senior GP at the service is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered services, 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 42 Care Quality Commission comment cards, and all of these were extremely positive about the care, service, and positive outcomes that patients had received. We spoke with three people during the inspection that also provided very positive feedback about the service.

Our key findings were:

• We saw strong clinical leadership within the service and the team worked in a united, supportive, and open manner.
• There was an effective system in place for reporting and recording significant events.
• Information about the service and how to complain was available and easy to understand. We found the service had acted appropriately, responded to complaints with an apology, and provided a full explanation.
• The service was aware of and complied with the requirements of the Duty of Candour.
• All staff requiring it for their role had received a Disclosure and Barring Service (DBS) check.
• Risks to patients were assessed and well managed.
• Actions had been taken when medicine alerts were received by the service. However, they lacked an audit trail to evidence the work.
• The service held a comprehensive central register of policies and procedures which were easily accessible to all staff.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had the skills, knowledge, and experience to deliver effective care and treatment.
• All patients told us they were treated with compassion, dignity, respect, and involved in the care and decisions about their treatment.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• We saw relevant emergency medicines and equipment were available.
• The service proactively sought feedback from staff and patients, which it acted on. Regular surveys were undertaken and reports collated from the findings and action taken where required.
• The service worked closely with an external organisation to promote men’s health checks at local events.

The area where the provider should make improvements are:

• Maintain the activities within the action plan, provided by the service on the day of inspection, to provide an audit trail of work.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care