This service is rated as Good overall.
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Soho Square as part of our inspection programme. Soho Square is part of The London Travel Clinic which provides travel immunisations, treatment and advice to fee paying patients.
We had previously inspected this service as part of our unrated programme of independent health inspections. At our last inspection undertaken on 4 July 2018 we found that the service was in breach of regulation 12 (safe care and treatment) and regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At that inspection we found that the provider had not adequately mitigated risks associated with infection control, non-clinical staff had not completed the requisite training, there was a lack of quality improvement activity, the complaints system was not advertised and there was no mechanism in place for gathering patient feedback. There was a lack of oversight in key areas of risk and safety and there was no business continuity plan.
At this inspection we found that most of these concerns had been resolved however the provider still did not have adequate oversight of risk management activities undertaken by third parties. It was not clear that all site-specific recommendations were followed up to ensure safety.
The clinical nurse lead for 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 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.
Two patients provided feedback to CQC about the service. Both patients said that the treatment provided was excellent and met their needs.
Our key findings were:
- The provider had systems in place in relation to safeguarding.
- Some risks were not adequately assessed, addressed or mitigated. For example, the provider did not have adequate oversight of risk management activities undertaken by third parties including in relation to fire safety and legionella.
- Appropriate emergency equipment was available on site. Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
- There were systems in place to report and discuss significant events.
- Medicines were appropriately managed and there were systems in place to respond to safety alerts.
- Care and treatment provided was effective and met patient needs.
- There were systems to review consultations, feedback to staff and implement improvements where needed.
- Feedback from patients was positive about access to treatment and the care provided and there was a system for managing complaints.
- Services were designed to respond to the needs of patients.
- Leadership was visible, and staff said that they felt happy to raise concerns or issues that arose.
- Governance systems were present in most areas although there were some instances where the provider did not have effective systems in place to oversee risk.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure that care and treatment is provided in a safe way.
The areas where the provider should make improvements are:
- Consider ways to better accommodate patients with accessibility needs.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care