30 May 2019
During a routine inspection
This service is rated as Good overall. (Previous inspection April 2018 – inspected but not rated.
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 on 30 May 2019 at Dr Susan Mary Horsewood-Lee – Oakley Street, to follow up on breaches of regulations.
CQC previously inspected the service on 27 April 2018 and asked the provider to make improvements regarding safe and well-led service. We checked these areas as part of this comprehensive inspection and found those concerns had been addressed. Following our previous inspection in April 2018, we issued two requirement notices for breaches of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment and Regulation 17 HSCA (RA) Regulations 2014 Good governance.
Dr Susan Horsewood-Lee provides a private doctors GP service to patients at 34 Oakley Street in the Royal Borough of Kensington and Chelsea. The service is situated in premises which are owned by the provider. The service is registered with the Care Quality Commission to provide the regulated activities of Treatment of disease, disorder or injury and Diagnostic and screening procedures and family planning.
Prior to our inspection, patients completed CQC comment cards telling us about their experiences of using the service. Thirty-seven people provided wholly positive feedback about the service. Dr Horsewood-Lee was described as caring, attentive and patients felt they were treated with respect.
Our key findings were:
- Action had been taken on all of the issues identified at the previous inspection; those we required and those we recommended.
- The service had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- We found evidence of improvement in monitoring and mitigating risks relating to the safety of service users.
- The premises were clean and well maintained, we saw evidence of actions taken to prevent and control the spread of infections.
- Not all emergency medicines were available as described in recognised guidance. There was a record kept of checks to make sure medicines were available, within their expiry dates, and in working order.
- At this inspection we found medical equipment had been calibrated to ensure it was safe to use.
- The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Services were provided to meet the needs of patients.
- There was a system for recording and acting on incidents, adverse events and safety alerts. The provider shared safety alerts with staff effectively.
- Staff felt involved and supported and worked well as a team.
- Patient feedback for the services offered was consistently positive.
The areas where the provider should make improvements are:
- Risk assess and make arrangements for the equipment and medicines needed for medical emergencies, including a defibrillator and pulse oximeter.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care