Waterloo Court

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. This was the first assessment of this service. This key question has been rated good.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. However, a policy/procedure had not been devised to support this process.

There had been no reported serious incidents since registration. At the time of inspection, the provider was in the process of developing an incident reporting system in collaboration with a group of phlebotomists. This system aimed to ensure that incidents and near misses were consistently recorded, with a clear focus on identifying themes, sharing learning across the service, and driving continuous improvement in practice.

We observed evidence the provider had reflected on feedback received through a complaint and had implemented changes to practice as a result. This demonstrated a commitment to learning and service improvement. There was no policy/procedure to support this system. Following the inspection, the provider submitted a copy of the policy they had developed to support this process.

The registered person demonstrated a clear understanding of the duty of candour. They had developed a policy outlining how they would promote an open and transparent culture, ensuring that people using the service and, where appropriate, their relatives were provided with a full, honest, and timely explanation when incidents occurred or when things went wrong.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service operated a structured referral process to ensure sufficient and relevant information was obtained to determine whether peoples’ needs could be safely met. External healthcare providers referred people to the service for phlebotomy, with those providers retaining responsibility for reviewing and managing test results.

People were also able to self-refer for blood tests; however, they were required to obtain the blood testing kits in advance.

The registered person had established arrangements to support continuity of care. Where required, people could be referred to a private GP service located on the same premises for clinical assessment, diagnosis, and review of blood test results. Test results could also be shared with the person’s own GP where required, to support ongoing care and treatment.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and correctly.

The registered person was trained in safeguarding up to level 3 in adults and children and they knew how to make a safeguarding alert, if it was required. They could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The registered person demonstrated an understanding of how to identify adults and children at risk of, or experiencing, significant harm. Processes included working in partnership with relevant agencies and contacting the local authority to discuss safeguarding alerts.

However, the service did not have access to a safeguarding lead trained to level 4 to provide specialist advice and support when required. The registered person was looking at exploring arrangements with another healthcare provider to access level 4 safeguarding expertise for guidance and support. Following the inspection the provider told us they were investigating how they can access level 4 safeguarding training.

The registered person was registered on the Disclosing and Baring (DBS) renewal service. The DBS Update Service (often referred to as the renewal service) is an online subscription that keeps the Standard or Enhanced Disclosure and Barring Service (DBS) certificate up to date. It allows people to reuse their certificate for multiple jobs without having to apply for a brand-new check each time.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks related to the procedure.

The registered person carried out a risk assessment as part of the consent process for people attending the service location. However, a formal written risk assessment was not routinely completed for home visits. The registered person advised they were in the process of developing a risk assessment process for the service provided.

People were able to provide feedback on the service, including through online review platforms. We reviewed a sample of these and found feedback to be consistently positive.

There was no formal policy to support the management of people who became unwell during attendance at the service. However, the registered person was trained in first aid and operated within a shared healthcare environment alongside a private GP practice, providing access to additional clinical support if required. Following the inspection the provider sent us a copy of a policy they had developed for the management of the deteriorating person.

The registered person advised in the event of a medical emergency, escalation procedures would be followed, including contacting emergency services.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered person ensured the environment was safe to minimise risks during blood collection procedures. The service operated from a rented room within a healthcare setting, which was accessible to people with disabilities, with ramp access available to support wheelchair users.

We saw evidence safety checks had been undertaken at this location, for example, electrical testing.

Equipment and processes were reviewed and adapted to improve safety and reduce risk. For example, a mobile trolley was introduced to enable safe and efficient access to equipment during procedures, minimising the need to reach across people or request their assistance. Fridge and freezer temperatures were maintained to the required safe levels and used for storage of blood sample when required whilst waiting on collection.

We scored the service as 3. The evidence showed a good standard. The registered person was qualified, skilled, and experienced, to meet people’s needs.

The service was provided by a suitably qualified and competent practitioner to meet the needs of people using the service. The registered person was the sole staff member and was trained and competent in undertaking blood collection procedures.

The registered person was up to date with mandatory training requirements. Ongoing supervision and professional support were accessed through participation in a national network of phlebotomists, where learning, best practice, and national guidance were shared and discussed.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection.

The registered person ensured equipment was maintained, clean, and fit for purpose. All areas were observed to be clean, suitably furnished, and well maintained.

During inspection, the registered person adhered to infection prevention and control principles, including effective hand hygiene. Personal protective equipment (PPE) was available, and we observed these were used during a blood collection procedure.

There were no medicines stored or administered at this service.