The Door W4 Limited

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 The Door W4 Limited as part of our inspection programme.

The service offers GP consultations to adults and children. The service offers skin related treatments including thread lift procedures and treatment for hyperhidrosis (a common condition in which a person sweats excessively). In addition, the service offers individualised bioidentical hormone replacement therapy (BHRT).

The service also offers dental services which were not inspected during this inspection.

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 exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Door W4 Limited provides a range of non-surgical cosmetic interventions, for example, botox and fillers which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The practice manager 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.

For reasons of safety and infection prevention and control related to the COVID-19 pandemic, we did not commission patient feedback with CQC comment cards. We spoke to three patients during this inspection and received positive feedback.

Our key findings were:

• Recruitment checks were not always carried out in accordance with regulations including Disclosure and Barring Service (DBS) checks.
• Consultations were mostly comprehensive. However, we noted that there was a lack of information in some care records. The risks associated with the use of unlicensed medicine were not documented in the consultation notes, not mentioned on the service’s website and appropriate consent forms were not completed.
• There were clear systems and processes to safeguard patients from abuse.
• Most staff had received training appropriate to their role. However, we noted two doctors had not received safeguarding children level three training.
• There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
• Staff members were knowledgeable and had the experience and skills required to carry out their roles.
• Patients were able to access care and treatment in a timely manner.
• Patients were asked for feedback following each appointment. This feedback was logged, analysed and shared with staff.
• The service had systems to manage and learn from complaints.
• Some emergency medicines were not in stock.

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.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

The areas where the provider should make improvements are:

• Consider organising sepsis awareness training for non-clinical staff.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care