The Care Quality Commission
  • Hospital
  • Independent hospital

West London Diagnostic Limited

Overall: Requires improvement read more about inspection ratings

66-68 South Ealing Road, London, W5 4QB 07868 724910

Provided and run by:
West London Diagnostic Limited

All Inspections

18 November 2022

During a routine inspection

We rated the provider as requires improvement because:

  • The provider did not have a full anaphylaxis kit in a grab bag containing all of the required medicines.
  • The service had improved its infection control practices since the last inspection however, we found a used glove in the medical trolley.
  • We found out of date equipment that was not required for the procedures undertaken at the service, in the medical trolley.
  • We found a sharps bin which had not been signed with its lid open which did not follow NICE guidance around the safe use and disposal of sharps.
  • The service’s policy for the scanning of children now made clear that the service did not undertake interventional procedures for children however it did not make clear that the service treated children who were 12 years old and above and we did not see a consent policy for children.
  • The medicines management policy had been updated since the last inspection but the changes the service made as a result of the inspection had not been incorporated into the document.
  • The service had improved its risk register outlining the risks to the service specifically however not all of the risks we found at the last inspection and this inspection were listed within the risk register.
  • The service had a vision for what it wanted to achieve, however, the strategy still did not detail how the service planned on achieving these goals.
  • The service did not have access to an interpreter for patients whose first language was not English but were in the process of sourcing a suitable interpreter service.
  • The clinic was based within a building that was not easily accessible for wheelchair users. There was ramp to get into the clinic, but the patient toilets were too narrow to accommodate wheelchair users.

However:

  • The service had ensured the ultrasound machine was serviced and PAT tested.
  • The service had improved its infection control practices. There was now a cleaning log for the ultrasound machine, clinic room, chairs and examination couch.
  • The service had actioned the National Patient Safety alert in relation to the safe use of ultrasound gel to reduce infection risk.
  • The service had implemented temperature monitoring of the medicines cupboard.
  • The service now had formal governance and team meeting minutes containing detailed discussion and actions.
  • The service had amended the complaints policy to ensure that the CQC’s remit was corrected reflected.
  • Staff spoke highly of the manager.
  • Patient records were comprehensive and clear.
  • The service now had written clinical protocols and policies in place.
  • The service now had a comprehensive audit schedule and had begun undertaking quality assurance for the ultrasound machine.
  • The service’s safeguarding policy now referred to up to date versions of national guidance and contained details on how staff can make a safeguarding referral.
  • The registered manager was clear on the requirements of a practising privileges policy and now ensured that the service followed its practising privileges policy.

On 14 September 2022, West London Diagnostic Limited was issued with an urgent notice to suspend their registration as a service provider in respect of regulated activities. This notice was served under Section 31 of the Health and Social Care Act 2008. We re-inspected the service on 18 November 2022 and found that the service had made significant improvements in the areas where we had concerns. Action we have asked the provider to take can be found at the end of this report.

9 September 2022

During a routine inspection

We rated the provider as inadequate because:

  • We found that the ultrasound machine had not been serviced and PAT tested.
  • The service did not control infection risk well. We found that there was no cleaning log for the clinic room, chairs, examination couch and ultrasound machine which was visibly dirty. Although staff changed their gloves between patients, they did not wash their hands between patients.
  • We found a sharps bin which was full and had not been dated or signed which did not follow NICE guidance around the safe use and disposal of sharps.
  • The service had not actioned the National Patient Safety alert in relation to the safe use of ultrasound gel to reduce infection risk and was decanting ultrasound gel into bottles which had old dates on them. This was an infection control risk.
  • The service did not have its own medicines management policy with detail around the medicines and procedures specifically related to the provider.
  • Medicines were stored in a locked cupboard in a room accessed by staff only however the temperature of the room where the medicines were stored was not being monitored or logged.
  • We found that the contents of the anaphylaxis kit were in date however there was no log of checks for the kit to make sure everything was in date and nothing was missing.
  • The service did not keep formal governance meeting minutes containing detailed discussion and actions.
  • The service’s policy for the scanning of children did not make clear that the service did not undertake interventional procedures for children.
  • The service’s complaints policy incorrectly stated that complaints can be referred to CQC for independent review.
  • The service did not have a deteriorating patient policy.
  • The provider did not ensure work was in line with evidence-based practice. The service did not have written clinical protocols and policies in place.
  • The service did not have effective audits in place to measure the effectiveness of the service that they provided. The service did not undertake quality assurance for the ultrasound machine.
  • The service did not have a comprehensive audit programme.
  • The service’s safeguarding policy referred to out of date versions of national guidance and did not contain details on how staff can make a safeguarding referral.
  • The service did not have a comprehensive risk register outlining the risks to the service specifically.
  • The registered manager was not clear on the requirements of a practising privileges policy and did not ensure that the service followed its practising privileges policy.
  • We found that some of the provider’s policies were missing, did not contain up to date guidance, reflected incorrect information, or was not sufficiently detailed.

However:

  • Patient feedback we reviewed and patients we spoke with were positive about the care and service they had received.
  • Staff we spoke with spoke highly of the manager.
  • Patient records were comprehensive and clear.
  • Staff treated patients with compassion and kindness, and took account of their individual needs

On 14 September 2022, West London Diagnostic Limited was issued with an urgent notice to suspend their registration as a service provider in respect of regulated activities. This notice was served under Section 31 of the Health and Social Care Act 2008. This notice of urgent suspension of their registration was given because we believe that a person will or may be exposed to the risk of harm if we do not take this action. Details of our findings and the evidence supporting our ratings are set out in our report.

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Victoria Vallance

Director of Secondary and Specialist Healthcare