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Inspection report

Date of Inspection: 27 February 2013
Date of Publication: 21 March 2013
Inspection Report published 21 March 2013 PDF | 76.61 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)

Meeting 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 carried out a visit on 27 February 2013, talked with staff and reviewed information we asked the provider to send to us.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

TPS was registered and accredited by Clinical Pathology Accreditation (UK) Ltd (CPA). We reviewed the overview report (January 2013) following the two day visit. The report noted "There are very good evaluation and improvement processes in place and the Operations/Quality Manager is extremely capable". There were no critical non conformities identified. There were 22 non-critical non conformities. The manager told us they had submitted a plan to the CPA to address all of these.

The senior manager told us the quality of the service and risks were discussed at the quarterly senior management meeting. We were told the agenda was a standard agenda which covered all the CPA standards. We reviewed the notes of the last meeting (January 2013). The notes included discussion and action points on a number of issues including the audit schedule, staffing and training, environment, equipment, results of the user survey, incident reporting and analysis. These demonstrated good governance and risk management systems in place.