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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

Effective

Updated 1 August 2018

Caring

Updated 1 August 2018

Responsive

Updated 1 August 2018

Well-led

Updated 1 August 2018