Spirit House

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 looked for evidence that people were protected from abuse and avoidable harm. This was the first inspection for this service since its registration with CQC. This key question has been rated as good. This meant people were safe and protected from harm.

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 clear process in place for dealing with complaints and significant events. They had developed a continuous improvement policy that outlined how to identify, report, manage and learn from improvement opportunities and ensure the appropriate action is taken. Reporting incidents was part of Spirit House’s commitment to learning and best practice. All staff were encouraged to report incidents. This information was logged so the provider could monitor themes. We saw evidence of the service handling significant events and complaints promptly, escalating them appropriately, documenting them formally whilst using them to drive improvement. Complaints and significant events were always an agenda item at the monthly governance committee.

The provider liaised with the service user’s registered GP for both the weight management programme and pulmonary rehabilitation services. In circumstances where a patient could not be accepted for treatment due to clinical, safety, or ethical reasons, the provider signposted them to the appropriate service to ensure safe and appropriate onward care. The weight loss programme was a private service that people paid for. At the time of the assessment, there were 13 people enrolled on the weight loss programme. People interested in the programme underwent a clinical review prior to treatment to ensure the care delivered was suitable for their needs. Whereas people were referred to the pulmonary rehabilitation services. 70% of referrals were from primary care, 25% were from secondary care and the remaining 5% of referrals were from community health professionals. This showed sustained engagement from GP practices and practice nursing teams and continued alignment with established referral pathways.

The service had appropriate safeguarding policies in place for reporting safeguarding concerns to keep people safe from harm. There was a safeguarding lead, and staff knew who this was. Staff knew how to identify, report and act when dealing with safeguarding concerns. Staff had completed the appropriate training for safeguarding adults and children. The provider understood mental health conditions including body dysmorphia, where people worry about flaws in their appearance that others cannot see. This was important to understand when people were interested in the weight management programme.

The service worked well with people to understand and manage risks. People completed regular questionnaires to ensure the service provided care to meet the needs of people that was safe, supportive and enabled people to do the things that mattered to them. The feedback we received through our ‘Give Feedback on Care’ process was positive in regard to people feeling involved in making decisions about their care and treatment. People told us they were given information and guidance about treatment options and the risks and benefits of these.

The weight management programme and some of the pulmonary rehabilitation programme was delivered remotely. However, some of the pulmonary rehabilitation sessions were completed face to face in venues in the community. For example, in a scout hut, village hall or gym room. The service completed risk assessments for each venue to ensure they were appropriate and safe, that could be easily accessible by public transport and had disabled access. The practice had procedures to ensure equipment, facilities and technology supported the delivery of safe care. The service had a health and safety policy and business continuity plan that was regularly reviewed.

The service made sure there were always enough qualified, skilled and experienced staff that worked well together to provide safe care and meet people’s individual needs. The weight loss programme was delivered by prescribing nurses, pharmacists, supported by a knowledgeable administration team. The pulmonary rehabilitation programme was delivered by a clinical team, supported by technical support instructors. Robust recruitment processes were in place to ensure appropriate numbers of suitably trained staff were employed to support the delivery of good quality care. A variety of internal and external training courses were completed. Staff had quarterly performance reviews including appraisals with their line manager and completed self-assessments to reflect on self-development. Clinical staff had clinical supervision meetings. The clinical lead conducted a notes audit to assess whether patient records are complete, accurate, and compliant with prescribing standards, and healthcare regulations. Findings showed that the re-audit compliance rate improved by 10% and met the 90% standard. Staff had opportunities to develop their knowledge. For example, they could attend respiratory network meetings and attend the National Respiratory Audit Programme, this was informative and encouraged staff to reflect and improve within their day job.

The service had an infection, prevention and control (IPC) policy that outlined the importance of assessing and managing the risk of infection. There was a designated IPC lead who was responsible for ensuring staff worked in line with the policy. Staff had completed appropriate IPC training relevant to their role.

The service had a clear eligibility criteria that determined who they could or couldn’t prescribe medication to based on safety. The service prescribed two weight loss medicines. They required a full medical history from the person’s registered GP before any treatment was provided. This ensured the prescribing decisions were informed by their full medical history, enhancing patient safety and supporting informed prescribing. . People were given clear detailed instructions regarding the medicines prescribed and were provided with information about how to safely use and store the weight loss injections. People prescribed medication for the weight loss programme, completed a monthly feedback form with pre-set answers to monitor them. For example, the effectiveness of the medicine and the side effects. If the answers were low risk, the medicine would continue to be prescribed. If they were higher risk, this would instigate a clinical review. If a patient did not complete the feedback form, the service would not continue to prescribe the medicine. We received positive feedback from people that told us the service closely monitored their progress and adjusted their treatment plan as needed. The registered GP practice was informed when they commenced and ceased prescribing for their patient with details of the medication. The service had effective systems to manage and respond to safety alerts and medicine recalls. We saw evidence of clinical audits being completed.