Gosforth Private Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We did not see evidence of a proactive learning culture in the clinic. There was no evidence of appropriate reporting of incidents or lessons learned. The service held infrequent management meetings. The service gathered feedback from patients regarding their experiences for only one part of the clinic. Not all clinic staff were aware of who the safeguarding lead was. There was no clear policy for ensuring the appropriate level of training for roles within the clinic. Since the last inspection, the service had updated the exclusion criteria for patients attending clinic. However, the website had not been updated with this information regarding baby scans. Staff had different opinions on how to manage a deteriorating patient, a concern at previous inspections. There was conflicting guidance provided in clinic policies regarding onward referrals for problems identified in baby scans. Staff had reported an equipment fault with the scanning machine but had continued to use it without it being fixed. Although environmental issues had occurred in non-clinical areas, there was no protocol or business continuity plan to manage such events. Not all staff had been present at emergency drills and some staff said they had never attended training scenarios for emergency situations. Not all staff had a job description. The service relied on mandatory training modules completed within the NHS, but not all were up to date. The environment was not visibly clean. Although, checklists showed cleaning of all surfaces had taken place, these were not clean during our visit. Although, the lack of cleanliness was identified as an IPC risk, the infection prevention and control policy included terms not relevant to the service. Audits were not carried out in line with clinic policies.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A manager gathered patient feedback following baby scans. They shared charts and graphs showing feedback with other managers. Patients were asked to complete an online questionnaire. Feedback related to the clinic facilities, environment and patient experiences of care and it was all positive. Feedback was not collected from patients undergoing cardiology scans.

We did not see any evidence of a proactive learning culture in the clinic. There was no evidence of lessons learned from incidents, and only one reported incident in 10 years. Staff told us there had been a fault on the ultrasound machine for some time. This had not been recorded as an incident. Managers intended to discuss incident reporting and safeguarding with staff to ensure they knew what to report in future. Managers also shared information with each other about possible frauds generated through social media for learning. Management meetings were normally held monthly and we were provided with minutes for May and June 2024. Staff recorded patient waiting times. These showed all appointments met the clinic’s 15-minute waiting time window. Although staff said patient feedback was collected, their own views and feedback were not sought to influence or improve the service. They felt it was difficult to engage with other staff. Staff worked four hours each week, and some did not regularly work together.

Potential incidents were not recorded in meeting minutes, or reported as incidents. There had been missed opportunities for recording and learning from incidents. Senior staff held a risk assessment incident log, and stated incidents were investigated, and included in minutes of the meetings. However, no incidents had been logged.

Management meeting minutes showed managers discussed policies and at the time of the assessment these were up to date.

The service had not collected feedback from partners.

The service had a data protection policy which described management, privacy, retention period, storage, and disposal of patient’s personal data in line with national guidance.

Scan images were held digitally on the scan machine and accessed via electronic password. They were archived to an electronic back up system, retained for 12 months and then erased.

Hard copy images were printed while women waited and sent electronically through an encrypted system.

We saw information, posters, and leaflets displayed in public areas to signpost service users to safeguarding help and staff told us they had access to safeguarding contacts information in clinical rooms.

The safeguarding lead was qualified to Level 5. The latest training they had completed was in 2021, but intercollegiate guidance states Designated Safeguarding Leads (DSLs) should receive formal refresher training every two years. All staff had completed safeguarding training appropriate to their substantive NHS role in accordance with the provider’s recruitment and safeguarding policies. However, not all staff were aware of who the safeguarding lead was and who to report concerns to within the organisation. The safeguarding lead expected staff to come to them with any safeguarding concerns. Senior staff told us they provided no care to children, and although a small number may attend the clinic with their families, staff would not expect any safeguarding concerns to arise. Staff did not appear to appreciate that any contact with patients or families may enable them to identify safeguarding issues or female genital mutilation (FGM) even though some baby scans could involve very intimate procedures to enable clear images in early pregnancy. Staff could only discuss how they would manage cases in other services.

There was an adult and children safeguarding policy in place. In addition, we saw local authority safeguarding teams’ contact details on display. Staff completed safeguarding adults and children to level 2. Some staff thought they had completed this to level 3 online as part of their NHS training, however this did not meet national guidance. There was no clear policy for ensuring the appropriate level for roles within the clinic were met.

The service did not provide any feedback on the involvement of people in managing risks or their understanding of risks.

We did not receive feedback from staff or leaders.

The service strongly recommended women attend all NHS antenatal appointments and staff shared key information to keep women safe when handing over their care to others. For example, when making an onward referral to an early pregnancy unit (EPU), sonographers sent a printed report of what they saw on the scan and images to the recipient service and women also received a copy.

Since the last inspection, the service had updated the exclusion criteria for baby scanning to include pregnant women with abdominal pain or bleeding. The clinic website had not been updated with this information so prospective patients would not be aware until this was discussed during the booking process.

Exclusion criteria for cardiology patients had been added to exclude anyone having had an acute cardiac episode, suffering from chest pains or shortness of breath. Staff said they would not turn away a patient walking past in an emergency. It was not clear how staff would manage such a situation. Some staff said they would provide treatment or use the clinic’s resuscitation equipment, others said they would call an emergency ambulance. This had been a concern at the previous inspection and remained so at this time.

The deteriorating patient policy dated August 2024 stated staff should ensure if a patient were to require emergency care, they should ensure the clinic’s resuscitation trolley is kept in the room with the patient until the ambulance crew arrive. It was not clear if the trolley was to be used by staff or ambulance crew. There was guidance provided for sonographers on finding fetal anomalies or maternal problems. Women were advised to immediately present to hospital, arrange an appointment at the local early pregnancy assessment unit (EPAU) or to call the woman’s midwife or GP depending on the individual circumstance.

The service ensured the effectiveness of people's care and treatment through an initial assessment of their health and care needs.

We did not receive feedback from staff or leaders.

We identified that staff had repeatedly recorded a fault on the ultrasound machine before it was then looked at for maintenance. This was not logged as an incident.

During this period, the ultrasound machine continued to be used by staff carrying out baby clinic scans. It was unknown what the impact of the fault displayed was, or if the equipment was still safe to use. At the point of assessment, the machine had been serviced.

Work was required on the building due to a leaking roof and staff had identified an “insect issue”. Meeting minutes stated the areas being worked on were not in clinic areas, but the work would influence the rest of the service. The clinic was closed during the remedial work. There was no protocol or process put in place following the roof leak and no business continuity plan to manage such an event in future.

Management meeting minutes noted sharps bins in some clinic rooms were out of date and required replacement. Minutes from June 2024 showed all ultrasound and ECG machines required servicing. The clinic owner was organising for this to be done.

Managers noted clinical dignity curtains, PAT testing, Legionella testing, fire inspection, and insurances were all in date.

Managers said they had carried out fire drills, but not all staff had been present, and some staff said they had never attended training scenarios for emergency situations.

Following assessment we received feedback from a patient who raised issues with staffing affecting their ongoing care and trteatment.

The service had six staff, all of whom worked part time, and clinicians worked clinic times only. Clinics were held once a week on separate days and staff rarely met each other at work.

The service employed two part time sonographers and a cardiac physiologist, who all had substantive NHS roles. Leaders told us staff checks take place before a staff member can work in the clinic. There was a checklist to show these were completed.

The clinic employed reception staff for clinic times only, one member of staff booked appointments for baby scans and ECGs. The clinic did not provide mandatory training for staff but relied upon training details from the NHS training site for those with NHS substantive roles. Leaders told us training from these substantive roles were used for evidence of ongoing staff training.

Not all staff held substantive NHS roles, and not all mandatory training was up to date.

The infection, prevention, and control (IPC) lead had not completed a full IPC training course, and their non-clinical IPC training was out of date.

The clinic did not provide training for staff on caring for people living with mental health needs.

Management meeting minutes stated a focus on the cleaner’s performance was planned for during building works. Staff told us there had been a separate deep clean carried out by an independent cleaning company.

We observed the service had safe staffing levels for the services delivered.

An ultrasound scan image audit carried out in May 2024 reported no negative findings and the image was clear. However, it was not clear how the auditor was qualified to carry out such an audit.

Cardiology scans were taken and reported on by the physiologist then every scan was discussed with the clinician. The clinician was then responsible for any clinical decision or referral.

There were no planned staffing rotas available at the time of assessment. A manager was not usually on site but was contactable by telephone when the clinic was open.

There was no lone working policy in place as we were told that current arrangements meant there was always a receptionist working when a clinic was running.

The service had no vacant posts.

The service had not collected people's views on the management of infection risk.

Hand hygiene audits were carried out every month for all clinical staff. Managers told us these were completed for one person each month and over the period of a year each member of staff would undergo two monthly assessments.

The hand hygiene audit checklist for 20 July 2024 showed results for two members of staff from different clinics. A further audit signed on 29 April 2024 showed results for three staff on the same day.

The staff member who leads and carries out the hand hygiene audits has received training in infection prevention and control for non-clinical staff only, which had expired at the time of assessment.

Staff said they cleaned beds and equipment before and after seeing patients. They donned personal protective equipment (PPE) and checked bins were empty before starting their clinics.

The environment was not visibly clean. The clinic provided examples of completed weekly cleaning checklists from July 2024. These showed all surfaces, shelves, sills, and blinds had been cleaned.

However, inspectors found floors and surfaces were not clean during the assessment.

Staff blamed the lack of cleanliness on the building works, in other areas of the clinic, and the timing of the CQC assessment. However, meeting minutes prior to our assessment showed managers had identified the lack of cleanliness in the clinic as an IPC risk.

Although a cleaning audit had been completed along with an action plan, measures were not in place to keep patients safe from infection through appropriate cleaning.

The Infection prevention and control policy used by Gosforth Private Clinic included some terms not relevant to the service such as “the IPC team” and “facilities management”. The policy did not appear to have been written with correct relevance to clinic systems and staff, it was not clear how staff should escalate IPC concerns or request support.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.