Archived: CVS Health Limited (Trinity House)

As a result of this inspection we had serious concerns about the safety of patients at this location and took immediate action to limit risk. We imposed a suspension of the service for eight weeks so that the provider could improve governance and safety checks at the location before caring for patients again.

We rated it as inadequate because:

• Systems to review self-employed clinical staff training were not monitored effectively, for example the provider did not make sure clinical staff had completed advanced life support training. However, the service provided mandatory training in key skills to administrative staff and made sure they completed it.
• Staff did not fully understand how to protect patients from abuse and the service did not understand the importance of working with other agencies to do so. Staff had limited training on how to recognise and report abuse and they were unsure of how to apply it.
• The maintenance and use of facilities and equipment did not keep people safe. Staff were not trained to routinely check or use lifesaving equipment. Equipment servicing was out of date and clinical waste was not managed well.
• Patient risk assessments were limited, staff completed basic risk assessments and updated them. Staff identified and acted upon patients at risk of deterioration although there was no standard operating procedure for dealing with emergency situations.
• The service did not manage patient safety incidents in line with national guidance. Staff recognised incidents and near misses, but they did not report them appropriately. Managers failed to ensure that incident forms were available for staff and that actions from patient safety incidents were implemented and monitored.
• The service did not provide assurance that care and treatment was based on national guidance and evidence-based practice. They did not have regular policy review meetings and some policies were outdated.
• The service did not monitor the effectiveness of care and treatment. They did not use findings to make improvements and could not benchmark outcomes for patients against national averages.
• The service did not have complete oversight of the competence of sub-contracted staff specific to their roles. The manager appraised administrative staff annually but did not always capture the competency evidence of clinical staff’s performance in a timely manner. The manager was unable to provide assurance that practising privileges were adequately monitored.
• Staff could not effectively support patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent, but they had not received the appropriate training on how to support patients who lacked capacity to make their own decisions or were experiencing mental health illness.
• Leaders did not always manage or understand the priorities and issues the service faced even though they had the skills and abilities to do so. Managers were not always visible in the service for patients and staff, which led to a lack of oversight on safety and governance.
• Leaders had not ensured the service had effective governance systems and processes to guarantee the service was managed safely and in compliance with the regulations. Not all staff were clear about their roles and accountabilities and they did not have regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders did not effectively use systems to manage performance. Risks and issues were not always identified and escalated appropriately to reduce their impact. They had plans to cope with unexpected events but did not have effective policies to limit risks. Staff did not have opportunities to contribute to decision-making to help avoid financial pressures, compromising the quality of care.
• Leaders reviewed improvements and innovation but failed to share practice updates with staff. Staff lacked understanding of quality improvement methods.

However:

• The provider managed infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
• Staff kept records of private patients’ care and treatment. Records were clear, up to date, stored securely and easily available to clinical staff providing care.
• Staff gave patients practical support and advice to lead healthier lives.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• Staff provided emotional support to patients to minimise their distress. They understood patients’ personal, cultural and religious needs.
• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
• People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards.
• People could give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
• The service had a vision for what it wanted to achieve and a strategy to turn it into action. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy.
• The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required via encrypted software.