This service is rated as
Requires improvement
overall. (Previous inspection January 2020 – Requires improvement) . This is the first inspection of this service under the current provider. At that the last inspection in January 2020 the service was operated by a different provider. The current provider therefore inherited this rating from the previous provider.
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? – Requires improvement
We carried out an announced comprehensive inspection at 112 Harley Street February 2022 as part of our inspection programme. This location is now operating under a new provider, TIC Health.
At the previous inspection in January 2020 we found concerns around significant events and safety management, staff recruitment and training and overall governance. At this inspection, whilst acknowledging that the service was now being operated by a new provider, we followed up on these concerns, as well as all of the key questions we look at as part of a comprehensive inspection.
The service is a small private GP practice with cardiac services.
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 general exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At 112 Harley Street, services are provided to patients under arrangements made by their employer/ a government department/an insurance provider with whom the servicer user holds an insurance policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at 112 Harley Street, we were only able to inspect the services which are not arranged for patients by their employers/ a government department/an insurance provider with whom the patient holds a policy (other than a standard health insurance policy).
One of the doctors at 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.
Our key findings were:
- The service did not have adequate governance systems in place. They were unable to demonstrate policies, procedures and activities to ensure safety and assurance that they were operating as intended.
- Risks to patients including around managing emergency medicines, staff recruitment and general risk assessment, monitoring and management processes were not clearly defined and mitigated against.
- Patients’ needs were effectively assessed and care and treatment was delivered appropriately. The practice prescribed medicines safely and effectively.
- Patients were treated with kindness, respect and compassion. Staff helped patients to be involved in decisions about their care and treatment.
- The service met people’s needs and patients were able to access care and treatment readily.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Review and improve systems and processes for learning, continuous improvement and innovation.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care