Leeds Screening Centre

This is our first inspection of this location. We rated it as requires improvement because:

• We had concerns about aspects of infection prevention and control (IPC) in the service such as the location of the only sink, the use of alcohol gel rather than handwashing as the primary method of hand decontamination, disposal of clinical waste, open top bins and the location of the sharps bin. Additionally, some chairs and beds had deteriorated and did not meet IPC standards because they could not be properly cleaned.
• The provider kept staff files, but these were not all up to date and did not all contain the full information required to demonstrate a robust recruitment process had been undertaken.
• Not all staff were confident about who to contact in the event of a safeguarding concern, staff had not undergone training about recognising domestic violence and the safeguarding lead did not meet intercollegiate standards with the level of safeguarding training they had undergone.
• Some patients commented and we saw that there were no blinds or curtains in place around beds to protect the privacy and dignity of patients.
• Some staff were unclear about what incidents and near misses they should report to the management team although there was a policy for staff to refer to.
• The service did not have a robust process for supporting patients whose first language was not English and who needed an interpreter or signer. The service did not have a process in place to make sure information passed on to patients by nonprofessional interpreters was accurate and complete.
• The provider was not able to provide quality checked leaflets in languages other than English.
• The provider did not have a specific policy in place to support staff managing patients who had additional support needs such as a learning disability, sensory impairment or dementia.
• Meeting minutes were not comprehensive and did not detail discussions or actions taken during meetings. They were not a clear record of meetings.
• There were breaches in regulations and risks within the service that had not been identified by the management team. Therefore, there was no mitigation in place to reduce risks or address regulation breaches.

However:

• The provider was able to show us policies, procedures, risk assessments and standard operating procedures they used to make sure patients were safe from the risk of harm.
• There was information for staff working at the service about their responsibilities in relation to clinical records and clinical records contained sufficient information to make sure patients were safe.
• Staff who worked for the service had the appropriate qualifications, skills and experience to make sure patients received care and treatment that was safe.
• There was a process in place to assure the provider that staff had an up to date registration and revalidation.
• The building was easy to access for those with a disability.
• Cleaning equipment and substances hazardous to health were locked away.
• Portable appliance testing (PAT), servicing and calibration, were completed and up to date.
• The provider was able to assure us that staff followed the correct process to obtain patient consent.
• Staff received annual appraisals and could access training to make sure their knowledge remained up to date. Staff training was up to date and there was a training plan in place for all staff.
• The provider gathered feedback from patients about their experiences of the service.
• There was information about how to make complaints displayed and the manager of the service dealt with complaints. Lessons learned were fed back to staff at quarterly staff meetings.
• Social media feedback and feedback gathered by the provider was predominantly positive and patients felt cared for, well informed, supported and involved in the care and treatment they received.
• There were governance processes in place, and these included how the provider monitored performance to ensure care and treatment was delivered in line with national guidance and work to improve the services delivered to patients.
• Clinical audit was carried out. Although this had been limited in the past 12 months because of the pandemic, the manager had plans in place for the coming 12 months which would see this increase.
• The provider worked closely with local NHS trusts to provide services in a joined up cohesive way and there were systems in place to monitor contracts and the quality of services delivered.