The Carriage House Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found systems designed to protect patients from the risk of harm were monitored and operated within a comprehensive system of governance. There was oversight of staffing requirements, safeguarding processes, management of premises and equipment, prescribing and infection control.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive culture of openness and honesty regarding the reporting of concerns and incidents by staff. Any events requiring further learning or required action were reviewed and promptly responded to. There was a log incidents and complaints to track the progress of investigations and identify themes from intelligence gathered from reported incidents and complaints. A periodic review of incidents was undertaken.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for assessing the needs of new patients to ensure adjustments could be made where necessary and safety information such as medical histories was recorded. The service worked with other providers to deliver shared care and when patients moved between services. We saw evidence that suggested referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to ensure patient safety and the best way to achieve that based on people’s individual needs. They concentrated on improving people’s lives while protecting their right to live in safety, free from abuse, discrimination and neglect.

Safeguarding policies were in place and available to staff, who were appropriately trained in safeguarding procedures. Action was taken when there was a risk of harm identified. Chaperones were available for patients if required.

The service worked with people in planning their care and treatment. They provided support and advice to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Staff had guidance to ensure patients could be signposted elsewhere when they needed emergency care.

The premises were clean and well maintained. Accessible treatment areas and an alternative entrance were available for people who had limited mobility or required wheelchair access. Clinical rooms had suitable flooring and work surfaces. Water systems were monitored for the risk of legionella.

There was a business continuity plan in place which was monitored and reviewed.

Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. Portable Appliance Testing was undertaken. Health and safety Risk assessments were in place and updated periodically.

Staff received appropriate training, supervision and appraisal. Professional development was identified for staff to enhance their ability to provide services and help their professional progression.

Staff background checks were undertaken on staff to ensure they were safe and fit to work with patients. This included Disclosure and Barring Checks (DBS) (background checks to ensure people are not barred from working in certain roles). As a result of inspection findings, the provider expanded the immunisation status checks undertaken on clinical staff immediately after our site visit.

The service assessed and managed the risk of infection. They detected and controlled the risk of healthcare related infections, with appropriate agencies where necessary.

We found that infection prevention control (IPC) training was available to staff. The service had a designated IPC lead. Annual IPC audits were conducted and any required actions were noted in the IPC annual report. Clinical waste was managed in line with guidance.

The service had systems to ensure medicines and treatments were safe and met people’s needs. The service had robust recall processes in place, to ensure patients were prompted when they needed a medicine review to ensure their prescribed medicines remained safe to continue. Prescriptions were processed securely. No medicines other than emergency medicines were stored onsite.

Emergency medicines and equipment were stocked, stored appropriately, monitored and replaced when necessary. The provider had not fully risk assessed all the emergency medicines that may be required as the care it provided expanded. As a result of findings from the inspection site visit, the service reviewed, risk assessed and expanded its stock of emergency medicines to reflect the additional services over recent years.