Background to this inspection
Updated
3 February 2023
Regency Clinic – City of London is an independent healthcare provider offering a range of “one-stop” gynaecology services and day case operations such as female genital surgery, trans-cervical fallopian tube unblocking, colposcopy, hysteroscopy and diagnostic ultrasound.
It is operated by Regency International Clinic Ltd. The service provides surgical and outpatient services. All surgical procedures are carried out on a day case basis. The service has an operating theatre that is also used for diagnostic imaging and a recovery area with two beds for day case patients.
We have inspected the service six times since 28 February 2018. Following an inspection on 25 August 2021 the service was urgently suspended under Section 31 of the Health and Social Care Act 2008. The service was placed into special measures.
Following an inspection on 12 July 2022, the service demonstrated they had met all the requirements of the suspension notice. The suspension was therefore removed.
This inspection was carried out on 28 November 2022. This was a routine focused inspection to review the inadequate ratings for safe and well-led and to consider whether the service was in a position to exit special measures.
Due to concerns highlighted in this report, we served a notice to the provider using our powers under Section 31 of the Health and Social Care Act 2008, suspending their registration for three months. Following the three month suspension, a further inspection will be carried out. If improvements have not been sustained, we will consider cancelling the services registration.
Updated
3 February 2023
Our rating of this service stayed the same. We rated it as inadequate because:
- The service did not have a process to identify when equipment was last cleaned.
- The service did not have any evidence of checks being completed for the automated external defibrillator. The equipment also did not have an inventory log or a weekly checklist.
- The service had out of date single use disposable medical equipment.
- The service had dirty equipment that had been recorded as sterilised.
- Although the service had a contract with a sterilisation company, the packaging of sterilised equipment had unclear dates written on them.
- The service had expired medicines in the lead consultants’ office (Co-amoxiclav).
- The service did not have an adequate process to manage risks or plans in place to reduce their impact. This included plans to cope with unexpected events.
- The service did not have a documented vision, set of values, or strategy developed with all relevant stakeholders.
- Although the service has made some improvements in their governance processes since the last inspection, further improvement was still required to ensure there was effective oversight and assurance for these processes.
- Although staff told us they assessed patients’ pain levels, we did not see any evidence of pain assessments using recognised pain tools in patient records or in the service.
- The service did not have suitable recruitment processes in place to ensure staff had the appropriate checks completed prior to their employment.
However:
- The service provided mandatory training in key skills to all staff and made sure everyone completed it.
- The service had enough staff to care for patients and keep them safe. Staff had training in key skills and understood how to protect patients from abuse.
- Records were clear, up to date, stored securely and easily available to all staff providing care.
- Staff knew what incidents to report and how to report them.
- Most staff had knowledge or understanding of duty of candour.
Although the provider made improvements to address the previous concerns, we still found several areas of concerns within Regulation 12 and Regulation 17.
Following this inspection in November 2022, the concerns identified resulted in an urgent suspension of all regulated activities imposed for a period of three months through a Section 31 Notice of Decision.