We carried out an announced comprehensive inspection at The London Circumcision Clinic on 2 August 2018, to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led? Overall, we found the service was not providing safe, effective and well-led services in accordance with the relevant regulations. The provider was issued with warning notices under regulations 12 and 17 of the Health and Social Care Act 20018 (Regulated Activities) Regulations 2014 due to not complying with their legal obligations around emergency procedures, including medicines, equipment and fire safety, infection prevention and control, recruitment and training and governance. The full comprehensive report published in September 2018 can be found by selecting the ‘all reports’ link for The London Circumcision Clinic on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 30 October 2018 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 2 August 2018. This inspection was not rated and the report covers our findings in relation to those requirements outlined in the issued warning notice.

Our findings were:

• There were policies and procedures to govern activities, but there was no system to update them.
• Staff recruitment files contained all the required information.
• A fire risk assessment had been completed but there were no smoke detectors or fire alarms in the premises.
• The service had a legionella risk assessment but there was no infection prevention and control risk assessment.
• There were emergency medicines and emergency equipment, but no system for checking these on a routine basis.
• There was no system for reviewing and acting on patient safety alerts, but post inspection we saw evidence that a system had been put in place.
• Non-Clinical staff had received no other training than safeguarding training.

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

• Ensure care and treatment is provided in a safe way to patients.

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

• Review the system for reviewing policies and procedures.
• Establish a system to routinely check emergency medicines and equipment to ensure they are in date and in good working order.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

We carried out an announced comprehensive inspection on 2 August 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 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.

The London Circumcision Clinic is an independent health service based in East London where child and adult circumcisions are carried out.

Our key findings were:

• Systems to keep patients safe and safeguarded from abuse were not effective.
• Except for complaints, the service had no policies and procedures to govern activities.
• Emergency equipment and procedures did not keep patient safe for example, there were no emergency medicines, an out of date oxygen cylinder and no defibrillator. The practice had not carried out any risk assessments to mitigate the risks associated with this.
• The service had not carried out any risk assessments including fire and infection and prevention control.
• There was no programme of quality improvement.
• Systems to protect patient personal information needed improving,
• With the exception of the surgeon the only training staff members had received was safeguarding.
• There was an effective system for seeking consent.
• There was a system to update external bodies such as GPs where necessary of care and treatment being provided.

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.

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

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

• Review with the system for storing patient records and prescription pads.

This inspection, carried out on 23 March 2014, was a follow-up inspection to check whether the service had made improvements to become compliant in relation to the essential standards for quality and safety. There was non-compliance in the areas of safeguarding people who use services from abuse, requirements relating to workers and assessing and monitoring the quality of the service.

We found that the provider was now meeting these standards. The staff had received training on the protection of vulnerable adults and children and knew the safeguarding procedures and how to report a safeguarding incident. The provider had followed a formal staff recruitment process and appropriate checks had been undertaken. The provider had put in place a quality monitoring system that included obtaining feedback from parents using a questionnaire survey and carrying out clinical audits.

We met several parents of babies and toddlers undergoing the circumcision procedure on the day of our inspection. They gave positive feedback about the service. One parent told us that they had received instructions to assist them to prepare for the procedure. Another parent said, “I am very pleased with the operation.”

We observed the interaction of the staff with people who used the service and found that staff were supportive and able to answer questions from the parents. One parent said, “The staff are very professional and caring.”

We spoke to family members of five children who used the service. One family member said “I’m very happy and satisfied with the service” although one person said, “The procedure felt a bit rushed, like you’re just a number.”

We found evidence that people or their families signed consent forms which were explained to them before the procedure took place. One family member said, “The receptionist went through the form with us to make sure we understood.”

People told us the provider asked about people's medical history and allergies, although we did not find evidence that this was documented. 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, “They help you relax.” There were arrangements in place to deal with foreseeable emergencies.

People told us they felt safe at the clinic. However, there was no information on safeguarding procedures at the time of our visit and staff had not received formal training around safeguarding children and vulnerable adults from abuse.

Some checks had been carried out before staff started work. There were no formal recruitment procedures in place. Most relatives told us they were happy with the staff.

Relatives told us they had been asked whether they were satisfied with the procedure. However, this was not documented and we did not find evidence that systems were in place to monitor the quality of the service.