The Care Quality Commission
  • Hospital
  • Independent hospital

Chear, Shepreth

Overall: Requires improvement read more about inspection ratings

30 Fowlmere Road, Shepreth, Royston, Hertfordshire, SG8 6QS (01763) 263333

Provided and run by:
Chear Ltd

All Inspections

14 August 2023

During an inspection looking at part of the service

Our rating of this service stayed the same. We rated it as requires improvement because :

  • Staff were not up to date in training in key skills, such as training in infection protection and control (IPC), and health and safety.
  • Staff had not completed training on recognising and responding to patients with a learning difficulty.
  • Staff did not have up to date safeguarding training on how to recognise and report abuse.
  • The service did not always assess risks and take measures to prevent such risks. The service did not have a fire risk assessment or Control of Substances Hazardous to Health (COSHH) risk assessments.
  • The service did not manage clinical waste in line with the Health Technical Memorandum 07:01.
  • The service did not always record consent in patient records or gain consent when sharing patient details with an independent body to investigate a complaint.
  • The service did not always fully investigate incidents and identify learning opportunities from them.
  • The service did not reference duty of candour in any of their policies and they were not always open, honest, and transparent when responding to patient complaints.
  • Managers did not monitor the effectiveness of the service. The service did not have an audit programme. We did not see any evidence of clinical audits, which assessed, monitored and improved the quality of the service.
  • The service did not document evidence of peer review or competency tests.
  • Leaders did not run services well using reliable information systems. The service did not engage routinely with patients to seek feedback and identify improvements.
  • Additional training and support was not given to the registered manager to support them in their role.

However:

  • The service had enough staff to care for patients. Staff understood how to protect patients from abuse. Staff kept good care records.
  • Staff provided good care and treatment. Key services were available to suit patients' needs.
  • Leaders 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.

9 June 2021

During a routine inspection

We have not previously inspected this location. At this inspection, we rated it as requires improvement because:

  • There were not effective systems and processes to maintain the overall governance of the service. We did not see evidence of sharing learning from incidents and complaints. There was no formalised approach to identify and manage risks within the service.
  • The systems and processes to ensure policies and guidelines were reviewed was not effective. The service did not have audit processes to monitor the effectiveness of care and treatment and staff appraisals tended to be informal.
  • Mandatory training for staff was limited and there was a lack of awareness of the risks to the service. Staff did not manage clinical waste well and equipment checks were not always documented.

However:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse. Staff kept detailed, clear care records.
  • Staff worked well together for the benefit of patients.
  • 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.
  • The service planned care to meet the needs of 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 for treatment.
  • Staff felt respected, supported and valued.
  • There was a strong focus on continuous learning and improvement.