We carried out an announced comprehensive inspection on 3 October 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 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.
Dr Sebastian Cummins 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.
This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Tarrant Street Clinic provides a range of non surgical cosmetic interventions, for example Dermapen and phototherapy which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.
19 patients provided feedback about the service. All the feedback we received was positive about the care and treatment received. Patients found the service to be professional, caring, supportive and maintained the privacy and dignity of patients at all times.
Our key findings were:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Patients were provided with detailed treatment plans to support their care and treatment.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Recruitment practices ensures information required by regulation was in place prior to the appointment of staff.
There were areas where the provider could make improvements and should:
- Review the information contained in the complaints procedure to add details of an appropriate body to refer complaints to as the next step if the complainant is unhappy with the practice’s response.
- Complete the update of the practice’s infection control audit and include the rationale/risk assessment for the legionella testing.
- Review the practice information to take account of access for people with limited mobility.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice