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Inspection report

Date of Inspection: 3, 14 January 2013
Date of Publication: 7 February 2013
Inspection Report published 7 February 2013 PDF

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 looked at the personal care or treatment records of people who use the service, carried out a visit on 3 January 2013 and 14 January 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

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

Reasons for our judgement

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We saw that the provider ran a patient survey and they had introduced an incentive to secure high response rates. The results of the survey were compiled by an external organisation and compared with the results of other similar services across Europe.

We reviewed the results of the previous year's survey and found that these were very positive with 92% of patients happy to recommend the service to others. People were encouraged to leave comments and suggestions also and we saw that many had chosen to praise the friendliness and helpfulness of the staff. One person wrote "Friendly, reassuring and efficient." and another wrote "I felt instantly reassured that I would only be treated if necessary and suitable and that I would be under no obligation."

The staff we spoke to cited examples of a number of changes that had been made to reflect the feedback and grumbles received from people who used the service. They told us that they had added more information about fees to the website. They also explained that as a result of feedback they had changed the topical anaesthetic they used to numb the skin before procedures to one that worked more quickly.

There was evidence that one of the managers undertook regular audits of the patient's records to ensure that staff were always making appropriate and contemporaneous notes of the treatments given.

The provider did not maintain a central complaints log or an adverse events, incidents, errors and near misses log but the manager agreed to set these documents up immediately. The staff were however clear about the need to report any of these type of events to the manager for investigation and action.

We saw that fire risk assessments of the premises were performed annually, thereby ensuring that the premises were safe in regard to risks of fire.