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Archived: The Calthorpe Clinic

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Inspection report

Date of Inspection: 20 January 2012
Date of Publication: 5 April 2012
Inspection Report published 5 April 2012 PDF | 67.17 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 20/01/2012, observed how people were being cared for, looked at records of people who use services, talked to staff, reviewed information from stakeholders and talked to people who use services.

Our judgement

The views of people are used to improve the quality of services delivered. The systems to identify and manage risks to people's health and welfare need to be improved.

User experience

The views of people were used to improve the quality of services delivered. Service satisfaction questionnaires were given to people at the end of their treatment, in order to seek their views about the service they received. We had been previously told by a senior manager that the results of the questionnaires had identified that they needed to take action regarding long waiting times. As a result of this, the clinic had introduced a new ‘patient pathway’ to help to ensure a smooth flow for people through the clinic. In the last 12 months a client liaison manager had been employed. They had responsibility for ensuring people had a positive experience at the clinic.

In August 2011, the registered provider invited an external youth organisation to the clinic. They undertook an audit of the clinic from the perspective of younger people and their findings were generally positive. We found that the clinic had acted on some, but not all of their recommendations.

We found that engagement with nursing and clinical staff was improving under the leadership of the new medical director and registered manager. One of the doctors at the clinic told us that suggestions made by staff were listened to. Staff told us about areas where the clinic was improving. One of the staff told us ‘’The new manager is working hard to upgrade the standards here, she has achieved a lot.’’

We saw that information about how to make a complaint was on display throughout the clinic, in the information booklet and on their web site. We found that there were systems in place for the management of complaints. We reviewed the complaints folder and found that appropriate and timely actions had been taken in response to complaints received. This included investigations and feedback to people that had made the complaint.

We found that the registered provider had no formal overview of the clinic. No quality monitoring visits had taken place. The registered provider had not prioritised actions needed at the clinic or identified what areas of risk needed to be monitored. The registered provider had not fully responded to our concerns about the standard of recruitment practice in the clinic. During one of our visits, we found that an audit had been completed of the recruitment information for medical staff but this had not been completed for nursing and other staff employed at the clinic. The audit had also not identified the areas around staff recruitment where we found that improvements were needed.

We found that the registered manager was monitoring risks to the safety of people who use the service and the quality of care they received. There was a reporting system in place to ensure that any incidents that occurred at the clinic were dealt with in an appropriate manner. Serious incidents were investigated by the registered manager so that the causes of the incident were identified and any action required taken. The outcomes of the investigations were fed back to commissioners and reviewed within the clinic to ensure learning was shared. A member of staff told us ‘’There is a medical committee that meets, this now is more regular, we feedback on practice and can convey any concerns.’’

We found that improvements and actions in response to risks identified were not always made in a timely manner or monitored to ensure changes in practice required were consistently followed through. For example, an infection control audit had recently taken place to check that there were good infection prevention and control arrangements in place. The audit recorded that many issues identified in 2010 remained outstanding. It identified several areas where improvements were needed. An action plan had been developed to address the issues, some of these had been completed and others were in progress at the time of our visit. A member of staff told us ‘’Since the new management has been in place clinic tidiness and cleanliness is much better, we are trying harder to meet

Other evidence

We have no other evidence for this outcome.