12 September 2022
During a routine inspection
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 Additionally, we found two out of date items in the emergency medicines stock and the defibrillator pads were out of date (with no spares available). The out of date items were removed on the day of inspection and evidence was seen that the service has since reordered two sets of defibrillator pads (adult and paediatric),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