19 January 2023
During an inspection looking at part of the service
The service is rated as good overall
We carried out an announced follow up inspection at Just Health on 19 January 2023. The ratings for each of the key questions is:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good (following our previous inspection in May 2022)
Are services responsive? – Good
Are services well-led? – Good
Following our previous inspection on 17 May 2022, the practice was rated requires improvement. overall and for key questions safe and well led. The key questions effective, caring and responsive were rated good. We issued the practice with a requirement notice for regulation 17(1) Good governance. This inspection identified improvements in all areas noted at the inspection in May 2022.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Just Health on our website at www.cqc.org.uk
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. Just Health provides a range of driver medical checks such those required to drive a heavy good vehicle (HGV) or a taxi. The activities undertaken in relation to this type of service are not within CQC scope of registration. Therefore, we did not inspect or report on these services.
Mr Yasir Jaleel is the nominated individual and the registered manager for the provider SSYNS Limited. 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.
Our key findings were:
- The provider offered a range of different services. Some of which were not within the scope of CQC registration.
- Those services that were within CQC scope were offered on a private, fee-paying basis only, and were accessible to patients who chose to use them.
- Services offered at the time of this inspection that were within the scope of registration were male infant non-therapeutic circumcisions and hay fever treatment. The website offered comprehensive information about these services and included details of the parameters of the services offered and the associated fees.
- Circumcision procedures were safely managed and there were effective levels of patient support and post-operative care.
- Systems to confirm parental identity and obtain written consent for the circumcision service was effective. Written consent was also obtained for the provision of the hay fever treatment.
- The service employed a small stable staff team. Team members spoken with were aware of their own role and responsibilities and told us they felt supported.
- The registered manager told us about the future plans for the service, and these included offering micro-ear suctioning and travel vaccinations.
We found that the issues identified at inspection in May 2022 had been addressed. These included:
- Staff recruitment records now complied with legislative requirements and staff risk assessments were now in place as appropriate.
- Evidence was available to demonstrate staff had received health and safety training as well as training in safeguarding and equality and diversity. Staff had also had an annual appraisal.
- A comprehensive range of policies and procedures were available and these included responding to a medical emergency, a recruitment policy and a business continuity plan.
- Improvements had been made to the infection control protocols and the sharps bin was clean, wall mounted, signed and dated
- Systems to monitor service provision in accordance with the service’s quality statement had been implemented.
In addition the areas we identified where the provider should improve had been addressed, for example:
- A system to monitor and record the expiry dates of the few medicines stocked by the service was in place.
- A risk assessment was implemented to mitigate the potential risk of carrying a small child up and down stairs following a surgical procedure.
- Patients consent was obtained to facilitate appropriate sharing of information with the patient’s NHS GP.
- An in-house system to request patient feedback was in the early stages of development.
The areas where the provider should make improvements are:
- Develop further as planned the in-house patient questionnaire.
- Implement the planned clinical audits.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services