Archived: Regency Clinic - City of London

Our rating of this location went down. We rated it as inadequate because:

• The service could not provide evidence to show that weekly checks were completed for the resuscitation equipment and the automated external defibrillator and there was no checklist of what should be checked.
• The suitcase containing resuscitation equipment was not fit for purpose as the foam padding and fabric had perished which produced a fine dust that contaminated the equipment.
• The deteriorating patient policy did not have clear guidance of what staff should do in the absence of a healthcare professional and there was no service level agreement with the nearby NHS hospital should a patient need to be transferred.
• The service did not have a clinician with advanced life support (ALS) training at the time of the inspection.
• The service did not have a backup generator in event of the loss of power to both lighting and equipment used during procedures.
• The service had excessive storage located between theatres and the recovery area which had evidence of dust collecting in some areas and presented a potential fire hazard and healthy and safety risk.
• The service did not securely store oxygen cylinders both in the recovery room and theatre.
• The service did not have a process to identify medicines that could be affected by safety alerts.
• The service did not complete prescription audits to ascertain if they were completed in full and appropriately.
• Although the service had updated policies to ensure they were in date, we found there were no clinical guidelines based on national guidance and evidence-based practice for the procedures provided.
• The service failed to show evidence on how it monitored performance using appropriate data in order to make improvements for service users.
• Although staff told us they assessed patients’ pain levels, we did not see any evidence of pain assessments using recognised pain tools in patient records and the clinic did not have a pain management policy in place.
• Although the service had an audit schedule, it had not been fully embedded at the time of the inspection. Some audits were not comprehensive as they did not include the expected criteria which meant the service did not monitor the effectiveness of care and treatment appropriately to make improvements and ensure good outcomes for patients.
• The service offered limited adjustments which took into account of patients’ individual needs and preferences.
• Although leaders were visible and approachable in the service for patients and staff, they did not understand and manage the priorities and issues the service faced.
• The service did not have a documented vision, set of values, or strategy, developed with all relevant stakeholders.
• Although the service has made some improvements in their governance processes since the last inspection, further improvement was still required to ensure there was effective oversight and assurance for these processes.
• The service did not have an adequate process to identify risks and issues or identify actions to reduce their impact. This included plans to cope with unexpected events.
• The service did not have a fully completed risk register and gaps identified included risk owner, date of review and expected date of completion. None of the risks identified during the inspection were listed on the risk register.
• The clinic’s website and patient information leaflets had not been updated to reflect the services provided.

However:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care.
• Staff knew what incidents to report and how to report them. Most staff had knowledge or understanding of duty of candour.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance to provide support and development.
• Although we were not able to speak with any patients, patient feedback showed that staff treated patients with compassion and kindness.
• Staff felt respected, supported and valued.
• Leaders and staff engaged with patients and staff.

Although the service had made improvements to address the Warning Notice for Regulation 17 and the Requirement Notices for Regulations 12 and 13 from the previous inspection, we still found several areas of concerns within Regulation 12 and 17.

Following this inspection in February 2022, the provider was rated inadequate and the concerns identified resulted in urgent suspension of all regulated activities imposed for a period of eight weeks through a Section 31 Notice of Decision. Details are at the end of the report.

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Victoria Vallance

Director of Secondary and Specialist Healthcare