The Care Quality Commission
  • Doctor
  • Independent doctor

Mayfield Clinic

Mayfield House, 256 Banbury Road, Oxford, Oxfordshire, OX2 7DE (01865) 423425

Provided and run by:
Healthwatch Limited

All Inspections

22 March 2018

During a routine inspection

We carried out an announced comprehensive inspection in December 2015 and we identified breaches of regulations. The location was previously registered with CQC under a different name; Oxford Private Medical Practice. Specifically we identified that the provider did not always operate effective governance procedures, identify and implement all staff training needs, manage medicines in line with all guidance or undertake staff checks as required by regulations. We asked the provider to inform us of the action they were going to take in order to ensure compliance with regulations.

We undertook an announced comprehensive inspection in 22 March 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 services 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.

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 service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The services provided which were within CQC’s powers to inspect were:

  • Private GP and nurse appointments which could be booked when required by patients. These could be booked for a number of patient needs including vaccinations, acute conditions, assessments of conditions, home visits among other services.
  • Ongoing management of patient’s medical conditions including therapies and assessments for mental health conditions.
  • Health checks for patients required by employers or as requested by patients.
  • Prescribing of acute medicines for therapeutic reasons.
  • Referrals to external private medical services or recommendations of referrals to patients’ NHS GPs.

There are a mixture of employed staff that provide care including five GPs and nurses. There were a mix of male and female staff.

The provider managed regulated activities from one site. The premises were altered to ensure they were appropriate and safe to provide clinical care.

There is a registered manager in post. 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.

We received 24 comment cards from patients who use Mayfield Clinic services and all were entirely positive about staff and the service patients had received.

Our key findings were:

  • The provider had systems in place to identify and learn from clinical practice in order to improve services where necessary.
  • Risks associated with the provision of services were well managed.
  • Medicines and related documentation were appropriately managed.
  • The necessary checks required on staff who provided care were in place.
  • Patients received full and detailed explanations of treatment including information enabling informed consent.
  • The service was caring, person centred and compassionate.
  • There were processes for receiving and acting on patient feedback.
  • There were appropriate governance arrangements in place. The provider ensured clinicians maintained an up to date knowledge in their specialism and undertook relevant training and revalidation.
  • There were systems in place to respond to incidents and complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) Chief Inspector of General Practice

15 December 2015

During a routine inspection

We carried out an announced comprehensive inspection on 15 December 2015 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 not providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was not 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 not providing well-led care in accordance with the relevant regulations.

Our key findings were:

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named healthcare professional and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • There was an effective system in place for reporting and recording significant events.

However,

  • Risks to patients were not always assessed and well managed, including those relating to recruitment checks.
  • The practice had a number of policies and procedures to govern activity, but some were missing or overdue a review.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Patient Group Directions which were used to administer medicines had not been correctly authorised in line with legislation.
  • Not all staff had the skills, knowledge and experience to deliver effective care and treatment.

We identified regulations that were not being met and the provider must:

  • Implement formal governance arrangements, local policies and systems for assessing and monitoring risks to comply with the requirements for the control of substances hazardous to health, health and safety and Mental Capacity Act and best interest decisions.
  • Implement and embed in practice a medical emergency policy, including a protocol for staff roles.
  • Ensure assessment, monitoring and improvement in quality of service is evidenced through of a programme of completed clinical audit cycles.
  • The provider must ensure they are complying with relevant Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Carry out Disclosure and Barring Service checks or detailed risk assessments for non-clinical staff undertaking chaperone duties.
  • Ensure all staff have evidence of an appropriate level of training suitable for their role, including; Mental Capacity Act 2005, Safeguarding and Health & Safety at work. Implement a programme of yearly appraisals and monitor ongoing training requirements and updates for all staff.
  • Ensure that Patient Group Directions comply with current legislation and meet legal requirements.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider should make improvements:

  • Review and update procedures and guidance.
  • Liaise with the landlord to ensure cleaning schedules for shared facilities are reviewed and monitored.

22 November 2013

During a routine inspection

We were unable to speak to people at the time of the inspection because no one was available.

People were given all the information they needed to make an informed decision about their care and treatment. Staff were observed to be respectful and helpful when speaking to people on the telephone and at reception.

Care was assessed and treatment delivered in a way to meet the needs of people who used the service. People were involved in discussions about their health and were able to make informed choices about their treatment.

There were safeguarding policy and procedures in place and some staff had received training.

There was a robust complaints procedure in place that was accessible to people using the service.

8 March 2013

During a routine inspection

We did not speak to people during the visit due to the nature of the service. We however spoke to spoke and reviewed documents. Staff we spoke with told us that they were happy with their job. They stated that they were given the opportunity to learn on the job which was beneficial to them. Staff were supported to enhance their skills and knowledge by attending relevant training to meet the needs of people and job role. They were also confident of making a meaningful contribution to the development of the service. This was through various forums available which included staff meetings.