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Archived: MSH Health & Wellbeing Community Interest Company

This service is now registered at a different address - see new profile


Inspection carried out on 1 and 2 February 2017

During a routine inspection

Services we do not rate

We regulate sexual health services, but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • Staff understood how to fulfil their responsibilities to raise concerns and report incidents.

  • Medicines management processes were fit for purpose and ensured people were kept safe from avoidable harm. This included the storage of refrigerated medicines in the main office and medicines used in the Queens Park sexual health service.

  • Deteriorating service users had their care reassessed and their care plan amended accordingly.

  • Staffing levels were suitable with an appropriate skill mix to meet the needs of people who used the service.

  • Staff adhered to the principles of infection prevention and control and demonstrated appropriate practice in hand hygiene and the use of personal protective equipment.

  • All clinical staff had appropriate safeguarding training and demonstrated how they used this to protect people from harm.

  • People supported by the domiciliary care service consistently told us staff who visited them were competent, well trained and professional in their approach to their work. Staff and their mix of skills were used innovatively to give them the time to develop positive and meaningful relationships with people to best meet their needs.

  • Sexual health services were provided in line with national guidance from the British Association of Sexual Health and HIV. These services were monitored using four key performance indicator targets. The service performed better than the target for two indicators and variably in the two other indicators. Where performance was variable, staff identified contributing factors and ensured the service was maintained.

  • Staff demonstrated a consistent focus on improving patient outcomes through opportunistic health promotion in sexual health services. This included providing free condoms, sexual health advice and signposting and smoking cessation support.

  • Staff used information and records systems that ensured they always had patient history information for appointments. There was evidence of communication with GPs and other healthcare services when needed to provide coordinated care.

  • People we spoke with consistently referred to staff as kind and caring people. All 123 Care Quality Commission comment cards received from sexual health services were positive and over 90% of people noted the friendliness and kindness of staff as key factors in their response.

  • The provider ensured individuals were at the heart of their care, underpinned by a staff team who placed a high value on partnership working. The service encouraged those who received domiciliary support to maintain and maximise their independence.

  • During all of our observations of care in sexual health services, staff demonstrated kindness, warmth and compassion. They involved people in discussions and decisions about their health and took the time to answer their questions.

  • Staff were trained to provide emotional support to people attending sexual health services.

  • The service provided domiciliary care and support that was focused on individual needs, preferences and routines. People's care and support was planned proactively and in partnership with them.

  • Care plans were in place which outlined people's care and support needs. Staff were extremely knowledgeable about people's support needs, their interests and preferences in order to provide a personalised domiciliary care service.

  • The provider placed a high level of importance on equality and diversity in respecting the needs and wishes of people who used the service and those who worked within it.

  • Staff provided a responsive and individualised sexual health advice, screening and support service that met the needs of the local population. This included providing advice and guidance based on sexual risk as well as recognition of the different needs of people based on sexual identity. Sexual health services included a mix of walk-in and pre-bookable appointments, and on-demand private appointments were available seven days a week.

  • Leadership within the organisation was visible. Communication was effective and the service actively sought and listened to the views of staff.

  • All staff were demonstrably passionate and enthusiastic about the service. Clinical staff involved in sexual health services had clear future plans to develop the service that aligned with the changing needs of the local population, particularly those living with HIV into old age.

However, we also found the following issues that the service provider needs to improve:

  • The fire safety policy and the fire risk assessment were out of date.

  • There was no process in place to formally audit success outcomes.

  • Supervision of staff was not regularly recorded.

  • Consent to provide support was not recorded consistently.

  • There was no risk register in operation to demonstrate how risk was managed.

  • There was no clearly defined deputy role to support the nurse manager in the event of any unplanned absence.

  • There was no formal system in place to seek feedback from those who used the domiciliary support service.