2 and 12 August 2016
During a routine inspection
We carried out an announced inspection visit on 2 August 2016 and an unannounced inspection on 12 August 2016.
Our key findings were as follows:
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On our announced inspection we found many safety concerns regarding infection control and hygiene; equipment and medicines management. There were also poor governance and leadership arrangements owing to a lack of registered manager; fit and proper persons checks not being carried out, contrary to regulation 19; and a poor culture among some operations managers. These findings are detailed in the report. However, when we returned for the unannounced it was clear that these issues had been resolved and systems and processes had been introduced to prevent these issues reoccurring. We were impressed with how quickly and effectively the service had addressed the problems.
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Staffing levels were sufficient to meet patient needs.
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Staff were confident in assessing and managing specific patient risks and processes were in place for the management of deteriorating patients.
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The concerns regarding infection control, equipment and medicines had all been resolved when we conducted a subsequent unannounced inspection.
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The service coordinated well with the local NHS ambulance provider to meet patients’ needs
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We spoke with six patients and one relative. All patients told us that staff were kind and caring.
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The service was planned to meet the needs of its contractual arrangements with health service providers. The service utilised its vehicles and resources effectively to meet patients’ needs.
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There was unanimously positive feedback from staff regarding the support and availability of the managing director
We saw several areas of good practice including:
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Safeguarding adult and children training to level two was completed to a high rate of over 99%.
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The culture amongst the staff we spoke with was good, and they liked working for the service.
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Mandatory training rates were good and staff were automatically booked onto refresher training courses when they were due for renewal.
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Staff were competent in carrying out their responsibilities and felt they received appropriate training and support for this.
However, there were also areas of poor practice where the location needs to make improvements.
The location must:
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Ensure that incident reporting procedures to ensure staff report all incidents and ‘near misses’; and implement systems for sharing learning and feedback with all staff following incidents and investigations to reduce the risk of incidents reoccurring.
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Ensure that governance processes and quality assurance measures and processes improve to provide effective oversight of all aspects of the service, in accordance with regulation 17.
The location should:
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Improve the governance systems within the service.
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Ensure that staff always receive adequate rest time between shifts, to reduce the potential risk of becoming fatigued.
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Have a registered manager in post. The service had not had a CQC registered manager in post for more than six months; although one had been appointed at the time of their inspection, they had not yet commenced work and were therefore not registered with CQC.
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Implement robust processes for risk assessing the vehicles for the transport of mental health patients, as this forms a significant part of the work of the service.