The Care Quality Commission
  • Doctor
  • Independent doctor

The Footmans Cottage Also known as Bridgewater Family Planning Service Association Limited

Overall: Good read more about inspection ratings

Castle Park, Frodsham, Cheshire, WA6 6SB (01928) 733722

Provided and run by:
Bridgewater Family Planning Service Association Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Footmans Cottage on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Footmans Cottage, you can give feedback on this service.

19 April 2023

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection March 2022 – Good with requires improvement in the key question of well led)

The key question inspected is rated as:

Are services well-led? – Good

We carried out an announced focused inspection at The Footmans Cottage to follow up on breaches of regulations. We followed up on the key question and areas of well led and the breach of Regulation 17.

  • At the last inspection (March 2022) we found that the provider must ensure effective governance systems are developed, implemented and monitored to ensure continuous quality assurance and improvement.

We also found that there were areas where the provider should make improvements. These were:

  • Implement and monitor a system for demonstrating staff had received appropriate recruitment checks and required training at appropriate intervals.
  • Implement and monitor an effective system for reviewing staff training, performance, learning and development needs.
  • Appoint an appropriately qualified infection control lead to support the registered manager.

CQC inspected the service on 19 April 2023 and checked these areas as part of this focussed inspection. We found improvements had been made and concerns had been resolved.

The provider Bridgewater Family Planning Service Association Ltd offers surgical vasectomy procedures for clients in Merseyside and Cheshire across four clinics based in NHS premises.

The managing director is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

The provider had demonstrated substantial improvements to quality and governance over the last 12 months. There were plans in place for future developments and service improvements supported by appropriate staffing and infrastructure.

At this inspection we found:

  • Effective governance systems had been developed, implemented and embedded. The new systems implemented enhanced continuous quality assurance and improvement.
  • Systems ensured reporting, analysing, learning and improvement from significant events and incidents. Evidence demonstrated improvements in practice made as a result.
  • Quality monitoring and improvement systems were in place including patient feedback, listening and learning from incidents and complaints and a clinical audit program.
  • Recommendations had been acted on and the provider now had effective systems for ensuring staff had received the appropriate recruitment checks, required training and development and appraisals.
  • An appropriately qualified clinical lead for infection prevention and control had been appointed.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

2/03/2022

During a routine inspection

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at The Footmans Cottage as part of our inspection programme. This location had not been inspected previously since registration.

The provider Bridgewater Family Planning Service Association Ltd offers surgical vasectomy procedures for clients in Merseyside and Cheshire across four clinics based in NHS premises.

The managing director is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the time of the inspection there were no patients attending or receiving regulated services and we were unable to ask them about the service. However, we reviewed some comments from patients the service had received online and one written piece of feedback.

Our key findings were:

  • Patients received detailed and clear information about their proposed treatment which enabled them to make an informed decision. This included costs (where applicable), risks and benefits of treatment.
  • Peri operative care and advice was clear and post-operative support was available.
  • Patients were offered appointments at a time convenient to them and treatment was offered in a timely manner.
  • Patients’ needs were fully assessed, and care and treatment was tailored to individual needs.
  • Clinicians assessed patients according to appropriate guidance, legislation and standards and delivered care and treatment in line with current evidence-based guidance.
  • Information about services and how to complain was available and easy to understand.
  • There were sufficient staff who were suitably qualified and trained. However, systems for monitoring staff performance and training and development needs should be improved.
  • There was not an effective governance framework in place in order to gain feedback or to assess, monitor and improve the quality of the services provided.
  • The provider was aware of the requirements of the Duty of Candour.

The areas where the provider must make improvements as they are in breach of regulations are:

  • The provider must ensure effective governance systems are developed, implemented and monitored to ensure continuous quality assurance and improvement.

You can see full details of the regulations not being met at the end of this report

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Implement and monitor a system for demonstrating staff had received appropriate recruitment checks and required training at appropriate intervals.
  • Implement and monitor an effective system for reviewing staff training, performance, learning and development needs.
  • Appoint an appropriately qualified infection control lead to support the registered manager.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care