27/06/2019
During a routine inspection
This service is rated as Good overall. (Previous inspection May 2018 – we found the service was providing treatment in accordance with the relevant regulations).
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 at Your Excellent Health Services as part of our inspection programme to rate independent health providers.
Your Excellent Health Service provides health screening, travel health advice and vaccination as well as seasonal vaccinations to adults and children.
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 general 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. At Your Excellent Health Service; occupational health and more specific private health services are provided to patients under arrangements made by their employer or an insurance company with whom the patient holds a policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Your Excellent Health Service, we were only able to inspect the services which are not arranged for patients by their employers or an insurance company with whom the patient holds a policy (other than a standard health insurance policy).
The provider 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.
We received 32 completed Care Quality Commission (CQC) comment cards which were all positive about the care a treatment received. People who accessed the service felt staff were kind, helpful, friendly and professional. Comments also showed that people were satisfied with the overall service they received, the service was easy to access, and staff were very welcoming as well as reassuring.
Our key findings were:
- The provider had systems and processes in place to keep patients safe and safeguarded from harm. Staff demonstrated awareness of local safeguarding arrangements to ensure the protection of vulnerable adults as well as children.
- The premises appeared clean and well maintained.
- Environmental risks were managed and reviewed by the building landlords. Although the service did not operate a process to gain assurance that environmental risks was being assessed and managed; the service addressed this during our inspection and provided evidence of completed risk assessments.
- Staff were given appropriate support and training to carry out their roles and responsibilities. During our inspection the service established a process to gain assurance that staff carrying out chaperoning duties had received training to carry out this role as well as a Disclosure and Barring Service check (DBS).
- Staff received verbal feedback from patient following their appointments. Staff explained feedback was consistently positive; and although feedback was not recorded we were told that if negative feedback was received then this would be used to support further improvements.
- Patient feedback received from completed CQC comment cards were consistently positive and in line with the services comments relating to verbal feedback they had received.
- The clinic was well organised, and the appointment system enabled timely access to services provided. Staff demonstrated awareness of the importance of being flexible when arranging medicals to ensure patients travel and work arrangements were not impacted.
- We saw some evidence of service improvement activity; however, the service had not yet established or operated a system for quality improvement cycles such as clinical audits as well as demonstrate how they routinely reviewed the effectiveness and appropriateness of their services.
The areas where the provider should make improvements are:
- Ensure systems and processes for monitoring the completion of environmental risks are embedded.
- Ensure system for checking that staff not directly employed by the service who carry out chaperoning duties have received a Disclosure and Barring Service check as well as training to enable them to carry out the role is embedded.
- Introduce internal systems and processes for quality improvement activities aimed at monitoring the effectiveness and appropriateness of the services.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care