16 November 2022
During a routine inspection
This practice is rated as Requires Improvement.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Insufficient evidence to rate
Are services caring? – Requires Improvement
Are services responsive? – Insufficient evidence to rate
Are services well-led? – Inadequate
How we carried out this inspection
We carried out an unannounced comprehensive inspection at Oaktree Clinic on 16 November 2022 as part of our inspection programme.
We spoke with three non-clinical staff. There were no clinical staff on site on the day of the inspection. We were unable to speak with the registered manager.
We requested information from the registered manager of the service informally and using legal powers under the Health and Social Care Act which included risk assessments, organisational policies, audits and quality improvement documents. We also requested staffing data, appraisals and supervision figures and mandatory training compliance. The manager failed to respond to these requests. Due to this failure, we were unable to inspect some areas of the service needed to undertake a fully informed inspection of the service.
There were no patients on site on the day of the inspection. After the inspection we requested contact details of patients so they could provide feedback on the service These were not supplied.
Since the inspection, the registered manager of Oaktree Clinic has begun the process to de-register the service and to de-register their status as registered manager for Oaktree Clinic.
The areas where the service must make improvements as they are in breach of regulations are:
The service must ensure that staff receive safeguarding training to enable them to identify when to make safeguarding referrals and how to do so. Safeguarding policies must reference current legislation and guidance. Managers must ensure staff understand their roles and accountabilities in respect of safeguarding (Regulation 13(2)).
The service must ensure it has effective clinical audits in place to enable managers to identify themes, trends or risks and monitor medication prescribing. This must include auditing the use of controlled drugs. (Regulation 12(2)(g)).
The service must ensure that all staff are trained to enable them to identify when to report incidents and how to do so. The service should ensure that staff in patient facing roles receive appropriate training to enable them to deal with patients in crisis. (Regulation 18(2)(a))
The service must ensure that managers have an effective system for monitoring statutory and mandatory training. (Regulation 17(2)).
The service must ensure that there are robust governance processes in place for the use of CCTV in patient areas. This should include recording the rationale for using CCTV and its’ impact on patients’ privacy and dignity. The service must ensure that patients are made aware that CCTV is present in clinical areas. (Regulation 17(1)).
Managers must ensure that there are effective processes in place for reviewing and updating organisational policies. (Regulation 17(2)(a)).
The areas where the service should make improvements are:
The service should take steps to address concerns raised by staff about managers not always being approachable, available or lacking compassion.
The service should take steps to address some of the concerns raised by staff about not feeling their wellbeing needs were met, and not having opportunities for career development opportunities.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services