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Inspection Summary


Overall summary & rating

Good

Updated 12 February 2020

Inspection areas

Safe

Good

Updated 12 February 2020

The x-ray machine had been decommissioned and the service was no longer provided. We found improvements in medicines management, staff training, safeguarding, waste control and risk management. Policies were up to date and relevant to the service; recruitment checks were documented, and all records completed, including appraisals. The processes for recording and learning from incidents had also been improved. The service had fitted a thermostat on all radiators to ensure the temperatures could be controlled and signs had been put up alerting patients to the fact that the radiators were hot.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. We reviewed the recruitment and training files for five members of staff and found that all of the recommended checks and training had been completed. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. One of the GPs was the lead for safeguarding and had been trained to level four for adult and child safeguarding. GPs and nurses were trained to level three for adult and child safeguarding, administration staff were trained to level two. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. There was a health and safety policy available and there was a system in place to liaise with the building management to conduct and review health and safety premises risk assessments, control of substances hazardous to health (COSHH) and legionella risk assessment and management (Legionella) is a term for a particular bacterium which can contaminate water systems in buildings).
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • The service advised us that they did not have an induction system for agency staff as they did not use them and would book appointments according to their capacity.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. The service had a defibrillator and oxygen on the premises and these were checked regularly. If items recommended in national guidance were not kept, there was an appropriate risk assessment to inform this decision.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place for nurses and doctors.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe; the service used a cloud-based system to store patient records. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Nurses prescribing travel vaccines did so under a patient-specific direction (PSD). A PSD is the traditional written instruction, signed by a doctor, dentist, or non-medical prescriber (hereafter referred to as “the prescriber”) for medicines to be supplied and/or administered to a named patient after the prescriber has assessed the patient on an individual basis.
  • The service prescribed some Schedule 2,3, 4 and 5 controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence). But did not hold stocks of these, they were monitored and audited to ensure that prescribing was appropriate and safe in line with national guidelines. The service had a controlled drugs policy to govern their use and carried out controlled drugs pink prescription audits (schedule 2-3) on a weekly basis and other controlled drugs (schedule 4 and 5) on a monthly basis.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • All staff had received Basic Life Support (BLS) training in the last year.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and took action to improve safety in the service. The service had strengthened the processes for reporting and dissemination learning from incidents since the last inspection. Incidents were logged, discussed and then learning was shared at clinical, administration and management meetings. There had been four incidents in the last year, one of which was when the service had a power cut. They followed their business continuity plan and ordered a back-up generator from their energy supplier. However, this took longer than the service expected, but the disruption to patients was minimal as this happened in the evening. The learning from this was the service decided to purchase their own generator to minimise disruption.
  • Report on Duty of Candour here: The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology.
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 12 February 2020

The service assessed need and delivered care in line with current legislation, standards and evidence-based guidance. The service was actively involved in quality improvement activity. Staff had the skills, knowledge and experience to carry out their roles. Staff worked together, and worked well with other organisations, to deliver effective care and treatment. Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence. The service obtained consent to care and treatment in line with legislation and guidance.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • All new patients were offered an initial 30-minute consultation with the first 15 minutes with the nurse who offered point of care testing (POCT). Point of care testing is defined as diagnostic testing that is performed at or near to the site of the patient with the result leading to a potential change in the care of that patient. Essentially it is a laboratory test conducted outside of the laboratory setting, usually by appropriately trained non-laboratory staff.
  • Clinicians had enough information to make or confirm a diagnosis. We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. The service had carried out seven audits in the last year, three of which were clinical. One of those audits was an antibiotic audit to ensure that they were prescribing appropriately. 50 patients were audited, and the service found that all but one had been prescribed appropriately. They felt the approach that they had adopted, to investigate further and the “watch and wait” (WW) measure was a more effective way to deal with certain minor illnesses. WW (also WAW) is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed
  • The service obtained patient feedback from informal discussions with patients, compliments, complaints, social media, email and monthly surveys. And used this information to improve services. For example, the service was in the process of updating their website due to comments from patients that it was out of date and they would like more online communication.
  • The service offered their patients Genetic testing to their patients to enable them to prescribe appropriate medicines with fewer side effects. Knowing a patients unique genetic code helped their doctors decide whether a medication was likely to harm patients or hurt them before they took it. It also helped them decide which medicines may be right for a patient at the right doses. We saw an example of one case which demonstrated therapeutic benefit as a result of the genetic testing which might not have occurred without information arising from genetic testing.
  • The service also held Patient forum meetings on a quarterly basis to get patients views on services and update them on updates to the service.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, where the service was unable/not the appropriate service to treat the patient, they were signposted to other services which may be more suitable such as their GP or a specialist consultant.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

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  • Staff had received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training. The service had developed a policy for Deprivation of Liberty Safeguards. Staff understood the Gillick competence and we saw evidence of this in clinical records we examined. (Gillick competence is a term used in medical law to decide whether a child (under 16 years of age) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge).
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 12 February 2020

Patients were treated with kindness, respect and compassion. Staff helped patients to be involved in decisions about their care and treatment. Staff respected patients’ privacy and dignity.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received.
  • Feedback from patients was positive about the way staff treat people, for example; results from the services monthly survey showed that patients felt that the service was “polite and efficient”, “very good” and “doctors and reception staff were lovely”. These results were consistent with the comments on the 17 CQC comment cards.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • All of the seven respondents to the November 2018 survey indicated that the attitude of the clinicians was excellent.

Responsive

Good

Updated 12 February 2020

The service organised and delivered services to meet patients’ needs. Patients were able to access care and treatment from the service within an appropriate timescale for their needs. The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, at a Patient Participation forum meeting feedback from patients indicated that they felt that the waiting room was too small. As a result, the service had established an additional waiting area, with a dedicated paediatric area.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • The service was open from Monday – Thursday 8am to 7pm, Friday 8am to 6pm, Saturday 9am to 12pm and Sunday 10am – 2pm.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available either online or from a leaflet available in reception. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, when a patient felt that there had been a confidentiality breach, the service investigated and once upheld apologised to the patient both verbally and in writing and arranged for the clinician to have additional training to ensure that there was not a reoccurrence of this.

Well-led

Good

Updated 12 February 2020

The service had dealt with the issues identified from the April 2017 inspection and leaders had the capacity and skills to deliver high-quality, sustainable care. The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients. The service had a culture of high-quality sustainable care and there were clear responsibilities, roles and systems of accountability to support good governance and management. There were clear and effective processes for managing risks, issues and performance. The service engaged with staff and patients and there was evidence of systems and processes for learning, continuous improvement and innovation.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance consistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. For example, the service ensured that all complaints were responded to both verbally and in writing and outlined any actions taken to the patient. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective clarity around processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.
  • There service used a cloud-based computer system to ensure that patient data was secure and accessible in the event that their premises was unavailable.

Engagement with patients, the public, staff and external partners

The service involved patients, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, the service held Patient forum meetings on a quarterly basis to get patients views on the service and update them on updates to the service.
  • Staff could describe to us the systems in place to give feedback, this was done via staff meetings. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work.
  • The service offered their patients Genetic testing to their patients which allowed their doctors to treat patients as unique individuals as they found that having this unique information affected how patients reacted to medicines that are prescribed by their doctors. They can also discover which foods, vitamins, minerals and also exercises will benefit the patients. The service started offering this service in 2015 in 2016 NHS England published the paper “Improving outcomes through personalised medicine.
  • The service offered new patients and patients who have not been seen in two years point of care testing; this included measuring weight, blood pressure, cardio risk, cholesterol and a urine dipstick test.
  • The service is currently refurbishing parts of the property to rent to allied health services, with a view to referring their patients more conveniently.
Checks on specific services

Outpatients and diagnostic imaging

Updated 18 October 2017

Outpatients and diagnostic imaging was the main service provided by the hospital.

We regulate clinics that provide treatment on an outpatient basis but we do not currently have a legal duty to rate them.