Background to this inspection
Updated
13 May 2022
The Centre for Reproductive Immunology and Pregnancy located in Epsom, is an independent service operated by Miscarriage Clinic Limited. The service offers women’s health support such as pregnancy care and delivery, prenatal testing and baby scans, management of hyperemesis gravidarum (excessive nausea and vomiting), general gynaecology and complimentary therapies. The service provides these services to people over 18-years-old.
The Centre for Reproductive Immunology and Pregnancy has been registered with CQC since July 2015 but has never been inspected previously. The service has had a CQC registered manager since registration and the current manager has been in post since 2016.
The service is registered to provide the following regulated activities:
• Diagnostics and screening procedures.
• Surgical procedures
• Treatment of disease, disorder or injury
Track record on safety (February 2021 to January 2022):
• No never events
• No serious incidents
• No incidences of healthcare acquired infection
Updated
13 May 2022
We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
- Staff followed COVID-19 guidelines and there was alcohol hand gel available for staff and patients throughout the clinic. On entry all visitors were asked questions relating to their current health and had their temperature taken to detect any signs of infection. All visitors were asked to use the alcohol hand gel.
- The clinic had a service level agreement with an infection prevention and control lead nurse from a local NHS trust to complete a yearly audit, and to provide staff with training specific to the clinic.
- Staff provided good care and treatment and gave patients pain relief when they needed it.
- Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and made sure patients had access to good information.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- The service’s website had a wealth of resources and signposted patients to information about fertility treatment and how to best support their health and wellbeing whilst undergoing treatment.
- Staff monitored waiting times and made sure patients could access emergency services when needed. In the unfortunate instance of a miscarriage being diagnosed, staff offered a quiet place for patients to have some time with a midwife to discuss their options. This included an offer of surgery, if chosen as treatment, within 48 hours from diagnosis to procedure with results and a follow up appointment within four weeks.
- Staff made sure patients with mental health issues received the necessary care to meet all their needs. All patients were reviewed by their consultant during the initial appointment and if identified as necessary, they were referred for counselling or to their GP before progressing with treatment.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait long for treatment.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and staff to plan and manage services and all staff were committed to improving services continually.
- All members of the leadership team had extensive experience in their area of interest and had previously worked, or continued to work, within the NHS as well as at the clinic.
- There was a strong emphasis on staff wellbeing. Staff had access to wellbeing support and the leadership team arranged two virtual mental health and wellbeing sessions with an external provider during the COVID-19 pandemic. Staff reported this had been helpful to manage their work and personal lives.
However:
- The clinic did not routinely audit the effectiveness of care and treatment provided.
- The clinic did not formally audit the quality of the ultrasound images and reports undertaken.
Diagnostic and screening services
Updated
13 May 2022
We rated this department as good because it provided a safe, caring, responsive and well led service. We do not rate effective.