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Inspection Summary


Overall summary & rating

Updated 1 August 2018

We carried out an announced comprehensive inspection on 10 May 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was not providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Prior to our inspection patients completed CQC comment cards telling us about their experiences of using the service. Thirty-three people provided wholly positive feedback about the service.

Our key findings were:

  • The service had systems to manage risk so that safety incidents were less likely to happen; however, these systems were not always effective, including providing appropriate emergency equipment, managing medicines safely, receiving and acting on safety alerts about medicines and equipment, and addressing infection prevention and control risks.
  • The service reviewed the effectiveness and appropriateness of the care it provided and it ensured that care and treatment was delivered according to evidence-based guidelines; however, the service did not have a quality improvement programme in place.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Services were provided to meet the needs of patients.
  • Patient feedback for the services offered was consistently positive.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

You can see full details of the regulations not being met at the end of this report.

We identified areas where the service could improve and should:

  • Review training requirements for staff including the provision of information governance training and formal training for chaperones.
  • Review medical indemnity arrangements for clinicians and clinicians’ assistants.
  • Review the provision of services and facilities for service users requiring additional access such as wheelchair users.
  • Consider business continuity arrangements in response to a major incident.
  • Review and improve the service’s quality improvement activity, developing a quality improvement programme.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Updated 1 August 2018

We found that this service was not providing safe care in accordance with the relevant regulations. You can see further details of the action we have told the provider to take in the Requirement Notices section at the end of the report.

  • The service’s systems, processes and practices to minimise risks to patient safety were not effective, as there was no automatic external defibrillator (AED) for use in an emergency, medicines were not safely stored and managed and infection prevention and control measures were not effective.

  • There was a system for reporting and recording significant events and sharing lessons to make sure action would be taken to improve safety.

  • There were systems in place so that when things went wrong, patients could be informed as soon as practicable, receive reasonable support, truthful information, and a written apology, including any actions to improve processes to prevent the same thing happening again.

  • Staff demonstrated that they understood their responsibilities and had received training on safeguarding children and vulnerable adults relevant to their role.

  • The service did not have business continuity plans in place to respond to non-clinical emergencies and major incidents.

  • Before consultations and at the appointment booking stage, staff checked patient identity by asking to confirm their name, date of birth and address provided at registration.

Effective

Updated 1 August 2018

We found that this service was providing effective care in accordance with the relevant regulations.

  • Staff were aware of and used current evidence based guidance relevant to their area of expertise to provide effective care.

  • Staff had the skills and knowledge to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for staff.

  • The service had effective arrangements in place for working with other health professionals to ensure quality of care for the patient.

  • Staff sought and recorded patients’ consent to care and treatment in line with legislation and guidance.

  • Patients’ care and treatment activities were reviewed to ensure compliance with best practice guidelines.

Caring

Updated 1 August 2018

We found that this service was providing caring services in accordance with the relevant regulations.

  • The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was accessible.

  • We saw systems, processes and practices allowing for patients to be treated with kindness and respect, and that maintained patient and information confidentiality.

  • Feedback we and the service received from patients about the service was wholly positive.

Responsive

Updated 1 August 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

  • The service had good facilities and was well equipped to treat patients and meet their needs, except for providing facilities for those with additional access requirements.

  • Information about how to complain and provide feedback was available and there were systems in place to respond appropriately and in a timely way to patient complaints and feedback.

  • Treatment costs were clearly laid out and explained in detail before treatment commenced.

Well-led

Updated 1 August 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had a clear vision to deliver high quality care for patients.

  • There was a clear leadership structure and staff felt supported.

  • The service had policies and procedures to govern activity and held governance meetings.

  • An overarching governance framework supported the delivery of high quality care. This included arrangements to monitor and improve quality and identify risk; however, these arrangements were not always effective.

  • Staff had received inductions, performance reviews and up to date training, however staff had not been trained in information governance.

  • The provider was aware of and had systems in place to meet the requirements of the duty of candour.
  • There was a culture of openness and honesty.

  • The service had recently introduced systems for being aware of notifiable safety incidents and sharing the information with staff and to ensure appropriate action was taken.

  • The service had systems and processes in place to collect and analyse feedback from staff and patients.