We carried out an announced comprehensive inspection on 17 November 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. This was the first inspection for this provider.

The Well Centre provides psychiatric assessments to patients with a wide variety of mental health needs including anxiety, depression, personality disorders, stress, addictions and eationg disorders. Patients can be referred through their GP or self-refer. Patients pay a fee for this service; once they have been assessed, they may be provided with a prescription, referred back to their GP or referred to other therapeutic services. On-going treatment is not provided by The Well Centre.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of providing the following regulated activity: Treatment of disease, disorder or injury.

Dr Tarik Fahal Jazaa Al-Kubaisy 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 obtained feedback from patients through three comment cards completed before the inspection.

Our key findings were:

• There were insufficient processes to identify, monitor and address current and future risks including risks to patient safety.
• There was a lack of focus on governance systems and processes.
• Staff did not receive up to date safeguarding and safety training appropriate to their role.
• There was ineffective recruitment oversight and HR checks.
• The service did not have arrangements to check that facilities and equipment were safe and in good working order.
• Patients’ health was monitored in relation to the use of medicines and followed up on appropriately.
• The clinician discussed treatment options with patients and supported them to make a decision. They assessed and recorded a patient’s mental capacity in line with guidance where appropriate.
• Patient feedback was positive about the service and patients fed back they were respected and listened to.

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

• Ensure 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 the quality assurance process including consideration of formal monitoring or audits.
• Review fire safety procedures to include a log of fire drills and a fire risk assessment.