1 March 2023
During an inspection looking at part of the service
This service is rated as Good overall. (Previous inspection July 2022 – Inadequate)
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 Mayfair Practice to follow-up on breaches of regulations. CQC previously inspected the service on July 2022 and required the provider to take action:
- To ensure patients are protected from abuse and improper treatment.
- To ensure care and treatment is provided in a safe way to patients.
- To establish effective systems and processes to ensure good governance in accordance with the fundamental standards.
CQC also reported that the provider should make the following improvements:
- Managers should have access to the online training platform.
- A comprehensive induction process for new staff should be put in place.
We checked these areas as part of this comprehensive inspection and found the provider had taken action to become compliant with the regulations and to address the previously identified areas for improvement.
Mayfair Practice is an independent health clinic which provides a GP service and also specialises in aesthetic medicine and dermatology.
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. Mayfair Practice provides a range of non-surgical cosmetic interventions, for example facial wrinkle injections and fillers which are not within CQC’s 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.
We received entirely positive feedback about the service from patients we interviewed during the inspection. Patients described the doctors as caring, professional and knowledgeable and the service overall as always welcoming and friendly.
Our key findings were:
- The service had improved systems to manage most risks so that safety incidents were less likely to happen.
- The provider had improved its systems to learn from safety incidents.
- Care and treatment was now being provided in a safe way.
- The service reviewed the effectiveness and appropriateness of the care provided. There was evidence of quality improvement activity.
- The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
- Patients were able to access care and treatment within an appropriate timescale for their needs.
- The service had systems in place to collect and analyse feedback from patients.
- There was a clear leadership structure to support good governance and management.
The areas where the provider should make improvements are:
- The service should embed and expand clinical audit as part of its improvement activity.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Primary Medical Services