28 April 2022
During an inspection looking at part of the service
We did not rate this service following this inspection.
•The service did not always control infection risk well. The service did not have systems to identify and prevent surgical site infections. The service did not use systems and processes to safely prescribe, administer, record and store medicines. The service did not have a clear process for the management of incidents. Staff were not trained in how to recognise and report incidents and near misses.
The service did not make sure staff were competent for their roles. Staff did not always support patients to make informed decisions about their care and treatment. They did not follow national guidance to ensure that patients gave consent in a two-stage process with a cooling off period of at least 14 days between stages.
Leaders did not operate effective governance processes throughout the service. Staff met monthly but they did not always discuss and learn from the performance of the service. Leaders and teams did not always use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and identify actions to reduce their impact.
However:
The clinical flooring in the treatment room had recently been replaced and the clinic appeared to be clean.
We wrote to the provider under Section 31 of the Health and Social Act 2008 to consider whether to use CQC’s regulatory powers to take potential enforcement action. We did this because we had reasonable cause to believe that, unless CQC acted people would be or may have been exposed to the risk of harm. The letter was in relation to the management of medicines, staff training and competence, and systems and processes to assess monito r and improve the quality and safety of the service. The provider responded to the letter and provided detailed information on how they are going to manage the issues detailed in the Section 31 letter of intent. CQC will continue to monitor this.