Background to this inspection
Updated
31 December 2021
Somerset Menopause Clinic was set up by the registered provider – Teresa Davison, who is a registered nurse, an independent prescriber and is accredited with the British Menopause Society as a Menopause Specialist.
The service is provided for women primarily aged between 40-60 years who mainly self-refer to the clinic. On occasions women are recommended to the clinic by their GP. The service is provided to approximately 16 patients per week.
Services offered include an initial consultation and assessment to identify an discuss symptoms and concerns, impact on the woman’s life, advice and options for treatment and access to information. The provider is able to discuss and if required, prescribe hormone replacement therapy for the individual. Lifestyle advice and support can also be provided but was not reviewed at this inspection as not part of a regulated activity.
The service operates from St Johns Physiotherapy, which is located at 4 St Johns Road, Taunton, TA1 4AZ. There is limited parking available at the rear of the building with public parking nearby.
Clinics are held on a Tuesday and Friday from 8.30am to 1pm where women can attend for face to face consultations. Online appointment or telephone appointments are held on a Wednesday. Other times may be booked following discussion with the provider. The provider does not employ any staff and services are provided solely by them. There is a receptionist in the centre who will take messages and refer callers to the provider.
The practice is registered with the Care Quality Commission to carry out the following regulated activities: treatment of disease, disorder or injury (TDDI).
How we inspected this service
Before our inspection we reviewed information we held about the clinic. We also requested and reviewed information from the provider before the inspection and information available on the providers’ website.
We carried out a site visit to the clinic, reviewed records and interviewed the provider.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
31 December 2021
This service is rated as
Good
overall.
The key questions are rated as:
Are services safe? – Good
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 Somerset Menopause Clinic as part of our current inspection programme.
The service registered with CQC under the Health and Social Care Act 2008 on 22 June 2020 and this is the first inspection since registration.
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. Somerset Menopause Clinic provides support and lifestyle advice to women regarding menopause which is not within CQC scope of registration. Therefore, we did not inspect or report on these services. Services offered which are in scope of registration include an initial consultation and assessment to identify an discuss symptoms and concerns, impact on the woman’s life, advice and options for treatment and access to information. The provider is able to discuss and if required, prescribe hormone replacement therapy for the individual.
Our key findings were:
- Care was provided in a way which kept patients safe and protected them from avoidable harm and safeguarded from abuse. The provider had a system for reporting, recording and learning from any significant events.
- The provider had taken precautions to reduce the risk to patients during the COVID-19 pandemic and on return to service delivery. However, the infection prevention and control policy and procedure did not detail these measures.
- The provider did not hold medicines. Prescriptions were stored securely, and the provider had implemented a system so they could track and audit all prescriptions provided to patients.
- Patients received effective care and treatment which met their needs. The provider followed national best practice guidelines and ensured care and treatment was evidenced based.
- The provider delivered a non-judgemental service and communicated well with patients. However, they had not made arrangements to provide support to patients whose first language was not English.
- The provider managed the service in a way which delivered high quality person centred care and treatment.
- Patients did not have access to the complaints procedure or information on how to make a complaint.
The areas where the provider should make improvements are:
- Review and develop the infection prevention and control policy and procedure to detail the actions taken to promote the control of infection from COVID-19.
- Provide clear and accessible information for patients on how to make a complaint should they need to do so.
- Develop systems to support patients whose first language is not English.
- The service had expanded but there was not a formal strategy and supporting business plan to continue the development of the service in line with the increasing demand.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care