Grosvenor Gardens Healthcare

Updated 11 October 2022

Women’s Health Dulwich is located at 17 Croxted Road, Norwood, London, SE21 8SZ, which was visited as part of the inspection process. The service is led by a female consultant obstetrician, gynaecologist and foetal medicine specialist. Further clinical staff employed by the service are three female consultant gynaecologists, one male consultant paediatrician, one female consultant paediatrician, one female GP, one female specialist colposcopy doctor, one male specialist obstetrics ultrasound doctor and two female physiotherapists. Additionally, there is one female operations manager, one male who provides information technology support, and one male financial analyst.

The service was established in 2020 primarily to provide private obstetrics, gynaecology, paediatric, physiotherapy and private GP services. Many clinicians operate from the service under practising privileges on a self-employed basis. The provider registered with the Care Quality Commission in 2020 to provide the following regulated activities of: Maternity and midwifery services; Family planning; Treatment of Disease, Disorder or Injury (TDDI); and Diagnostic and Screening procedures.

The service has a mixture of both adult and children patients, and all services and pricing are advertised on the Women’s Health Dulwich website (www.womenshealthdulwich.com).

The service is open:

• Monday to Friday 9am – 6pm.
• Saturday 9am – 2pm.

How we inspected this service

During this inspection we:

• Spoke with a range of staff including a doctor, who is also the registered manager, the operations manager and non-clinical staff.
• Looked at the systems in place for the running of the service.
• Looked at rooms and equipment used in the delivery of the service.
• Viewed a sample of key policies and procedures.
• Explored how clinical decisions were made.
• Spoke with three patients to ascertain their views on the service provided.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 11 October 2022

This service is rated as Good overall.

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? – Good

We carried out an announced comprehensive inspection at Women’s Health Dulwich on 12 September 2022 as part of our rating inspection programme for independent health services. This was the first full inspection of this service.

Women’s Health Dulwich was established and registered with the Care Quality Commission in 2020. The service offers private GP, gynaecology, paediatric, ultrasound and maternity services, as well as offering physiotherapy services at another site.

The principal doctor 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.

As part of this inspection, patients of the practice were asked to give feedback to CQC about their experiences of using the service. We spoke with three patients about the service they have received, and all comments received were positive, mentioning: staff were professional, helpful and efficient; treatment options were always fully explained and tailored to individual needs; and a responsive service with a dedicated doctor.

Our key findings were:

• We found a number of items were missing from the emergency medicines supply that we would expect to be stocked, with no accompanying risk assessment to justify their absence. Additionally, we found two out of date items in the emergency medicines stock and the defibrillator pads were out of date (with no spares available). The out of date items were removed on the day of inspection and evidence was seen that the service has since reordered two sets of defibrillator pads (adult and paediatric), and had obtained the items missing from the emergency medicines supply.
• Not all clinical staff had the appropriate safeguarding training relevant to their role. For example, we found that although children were sometimes treated at the service, not all doctors had received level 3 children’s safeguarding training.
• Clinical notes were kept in line with best practice guidance, with evidence seen that thorough and detailed feedback from consultations was provided to patients.
• There were both reported and observed positive relations between staff and management.
• Practice policies were in place and shown to be reviewed regularly.
• The service was proactive in responding to feedback and complaints from patients. We saw evidence of implemented changes (e.g. email templates) that had been introduced following feedback from patient experience.
• We saw no evidence of discrimination when making care and treatment decisions.
• Feedback from patients was positive about the way staff treated people.
• Information about how to raise concerns was available.

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Consider including Mental Capacity Act training as mandatory training for non-clinical staff.
• Implement a hearing loop within the service to improve accessibility for those who may be hard of hearing.
• Consider adding a message to the service’s telephone message advising patients on how to seek out of hours support.
• Consider implementing a schedule for audits to ensure regular two-cycle audits are completed.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services