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Inspection Summary


Overall summary & rating

Good

Updated 23 September 2019

This service is rated as Good overall. (Previous inspection November 2017, the clinic was not rated and was meeting the requirements).

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? – Good

We carried out an announced comprehensive inspection at Chelsea Bridge Clinic as part of our inspection programme. We inspected all five key questions.

Aspen Medical Services Ltd provides private medical services from purpose built premises at Chelsea Bridge Clinic, Ground Floor Riverfront, Howard Building, London, SW8 4NN. The clinic provides services in dermatology, orthopaedics and general health (including general practice appointments).

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Chelsea Bridge Clinic provides a range of non-medical and complimentary therapies (e.g. physiotherapy, acupuncture, coaching, personal training and hyperbaric oxygen therapy) and cosmetic interventions (including laser aesthetics) which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The clinic manager 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.

Fifteen people provided feedback about the service.

Our key findings were:

  • There were systems to assess, monitor and manage risks to patient safety.
  • Systems and processes kept patients safe from abuse. Staff whose records we checked had completed appropriate safeguarding training for their role, although it was not practice policy that clinical staff should have level three training in child safeguarding. There was a system to assure that an adult accompanying a child had parental authority, but this was informal rather than formally documented.
  • There was equipment and medicines to deal with medical emergencies. These were adequate for the services fully implemented at the time of the inspection, but did not cover all of the most common risks for the services that the clinic provided.
  • We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).
  • There was quality improvement activity, although this was not consistent across the whole service. The clinic was developing measures of effectiveness for its newer medical services.
  • Staff had the skills, knowledge and experience to carry out their roles, and worked together, and worked well with other organisations, to deliver effective care and treatment.
  • Staff supported patients to manage their own health, and obtained consent in line with legislation and guidance.
  • Staff treated patients with kindness, respect and compassion and helped patients to be involved in decisions about care and treatment.
  • The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.

We saw the following outstanding practice:

  • The service had reviewed safety systems in other healthcare systems and other industries and had recently introduced a ‘good catch’ process. Good catches were defined as issues that could have caused injury, incident or a deterioration in the quality of care had they not been rectified.
  • Good catches were noted on a form that included the issue identified, the risk level, the root and contributory cause and the action taken.
  • The service was sharing the good catches with staff and using them to identify areas for staff/policy development. Short video reminders for staff were being created to reinforce key messages.

The areas where the provider should make improvements are:

  • Review the training policy to check this is aligned with national guidance, e.g. on safeguarding. Consider formalising the system for verifying patient identity and adults accompanying children.
  • Review the emergency medicines and equipment to check they are adequate for the services being developed.
  • Review measures of effectiveness to develop comprehensive measures across all of the services offered. Consider how governance will remain effective when new specialities are added.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 23 September 2019

  • The service had systems to keep people safe and safeguarded from abuse. Staff who’s training records we reviewed had received appropriate training for their role.
  • There were systems to assess, monitor and manage risks to patient safety.
  • Staff had the information they needed to deliver safe care and treatment to patients.
  • The service had reliable systems for appropriate and safe handling of medicines. There was a supply of emergency medicines that was adequate for the services provided, but which needed to be reviewed in the light of the services that were being developed.
  • The service learned and made improvements when things went wrong. The service had introduced a ‘good catch’ process to try to identify and rectify issues in a positive way.
  • The service had a system in place to share safety alerts with to all members of staff. We heard of examples of action taken as a result, and this was recorded for devices alerts but not for alerts on medicines. The provider told us shortly after the inspection that these were now recorded.
  • There were systems to assure that an adult accompanying a child had parental authority, but these were informal rather than formally documented.

Safety systems and processes

The service

had

clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority, but these were informal rather than formally documented.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • The service’s policy was that all staff should complete level two training in safeguarding children and adults. Doctors we checked had completed safeguarding children level three (as recommended by national guidance). Staff we spoke to knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There were systems to manage infection prevention and control, including legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.
  • The service had systems to check photographic identity documents for new patients, but these had not yet been consistently implemented.

Information to deliver safe care and treatment

Staff

had

the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had

reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use. The clinic had risk assessed to determine the emergency medicines required. These were adequate for the services fully implemented at the time of the inspection, but did not cover all of the most common risks for the services that the clinic was developing (e.g. there was no emergency medicine to treat asthma).
  • There had been relatively little prescribing so far, and oversight was informal. The service was developing plans for medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.

Track record on safety and incidents

The service

had

a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • The service had reviewed safety systems in other healthcare systems and other industries and had recently introduced a ‘good catch’ process. Good catches were defined as issues that could have caused injury, incident or a deterioration in the quality of care had they not been rectified. Good catches were noted on a form that included the issue identified, the risk level, the root and contributory cause and the action taken. The service was sharing the good catches with staff and using them to identify areas for staff/policy development. Short video reminders for staff were being created to reinforce key messages.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, shared lessons and took action to improve safety in the service. None of the events that occurred met the threshold for the Duty of Candour, but the provider was aware of the requirements.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology. They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff. There was a log of actions taken in response to alerts relating to devices, but not of action in response to medicines alerts. The service told us shortly after the inspection that this had been put in place.

Effective

Good

Updated 23 September 2019

  • We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).
  • There was quality improvement activity, although this was not consistent across the whole service. The clinic was developing measures of effectiveness for its newer medical services.
  • Staff had the skills, knowledge and experience to carry out their roles, and worked together, and worked well with other organisations, to deliver effective care and treatment.
  • Staff supported patients to manage their own health, and obtained consent in line with legislation and guidance.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The clinic was actively involved in quality improvement activity. Monitoring and quality improvement was well established for some of the clinic’s services, and was being developed for others.

  • The service used information about care and treatment to make improvements. There were established formal quality improvement mechanisms for the clinic’s services that had been running for longest (but that were not within scope for CQC regulation). Monitoring of services that were within scope was less established, and was carried out through policy and procedure reviews and random sample checks of patient records. This internal monitoring was supplemented by patient feedback as to the treatment outcome. The service had established the clinical outcomes to be monitored for the GP service (including resolution of presenting symptoms, patient education and lifestyle improvement) and was discussing how to monitor these.

  • The clinic had recently introduced a system of quarterly service reviews for each service, where quality improvement was discussed (along with good catches, significant events and complaints).

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or Nursing and Midwifery Council and were up to date with revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with other services when appropriate. For example, when patients were referred to other services for specialist care.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP when they first registered with the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing. For example, medicines liable to abuse or misuse. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 23 September 2019

  • Staff treated patients with kindness, respect and compassion.
  • Staff helped patients to be involved in decisions about care and treatment.
  • The service respected patients’ privacy and dignity.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • The clinic used ‘health maps’ based on patient’s assessment data to help patients understand their health and the priorities for treatment. We heard examples of when this had allowed GPs to better explain why they would not prescribe the medicine that the patient wished, or refer the patient for unnecessary tests, and help patients recognise how they could improve their health by changing lifestyle.
  • The clinic had launched a campaign on social media to engage the local community on health prevention and optimisation, and had completed 183 free health map assessments. This represented 20% of the population of the nearby Battersea Power Station housing development. The clinic had a goal of providing health maps for 40% of the Battersea Power Station development by the end of the year.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 23 September 2019

  • The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.

    • The service was developing GP services in response to the development of the area around the clinic. New homes for 6000 people had been built in the last 12 months, and more than 17,000 were being developed, and there was currently no local healthcare provision. The service had run outreach events with local people, offering free health assessments. In response to feedback that local residents had suggestions/requests for services the clinic could offer, but felt uncomfortable entering the clinic to make these face-to-face, the clinic placed a suggestions box on the wall outside the clinic. Through cards in this box, the clinic had requests for a phlebotomy service at the weekend, and a gynaecology service, both of which were being rolled out.
    • There was no pharmacy close to the clinic, so the provider had made arrangements with other services to ensure that patients could get access to the medicines they needed. In response to requests for additional post-operative support, the provider was developing a new service with a domiciliary care agency to provide at home nursing as part of the post-operative care package.

  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. There was a hearing loop to support patients with a hearing impairment. Key forms were available in large print and braille. We heard examples of particular actions taken to support individual patients with other specific needs.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. Patients assessed as needing to be seen by a specialist doctor with practising privileges at the clinic could be seen by them within 24 hours. Urgent referrals to other services were made and followed up.
  • Patients told us on comment cards that they had timely access to care and treatment. This was mirrored by survey data gathered by the service and online comments. Satisfaction rates consistently exceeded the Clinic's 90% target, and online reviews almost entirely scored the Clinic and its practitioners at 4 (very good) or 5 (excellent).

  • The provider monitored several key performance indicators related to access, for example that all calls were answered within 5 rings and all emails answered within 2 hours, and that 95% of patients could make an appointment within the same week. We saw evidence that the service was meeting these performance indicators.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of other organisations they could contact should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, after a complaint that involved patient expectation, the service amended the consent form.

Well-led

Good

Updated 23 September 2019

  • Leaders had the capacity and skills to deliver high-quality, sustainable care.
  • The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.
  • The service had a culture of high-quality sustainable care.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • There were clear and effective processes for managing risks, issues and performance.
  • The service acted on appropriate and accurate information.
  • The service involved patients, the public, staff and external partners to support high-quality sustainable services.
  • There were evidence of systems and processes for learning, continuous improvement and innovation.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. For example, the service had struggled with finding the right staff, so was adopting new strategies, including the use of specialist recruiters.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners and taking into account the needs of the local population.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy. Governance and monitoring were developed prior to, or in tandem with, development of new services.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All employed staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff. The clinic helped their staff to look after their health with access to support such as hyperbaric oxygen therapy, stress therapy, and dance classes.

  • The service actively promoted equality and diversity. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The provider had revised the governance framework to reflect the clinic’s expanded scope, and the new framework was formally documented. One key element was the recent creation of a quarterly medical advisory committee (to consider outputs from quarterly service reviews and quarterly patient participation group meetings). The medical advisory committee had met once, agreed terms of reference and some actions (which were complete or underway).
  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. There were monthly audits of the safety processes and periodic audits of staff knowledge and application of policies.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. There had been limited material, within the services within scope of CQC regulation, for formal clinical audit. Performance of clinical staff could be demonstrated through audit of their consultations and patient feedback. Plans were in place to audit prescribing, referrals and outcomes more systematically for the expanding medical services.

  • Leaders had oversight of safety alerts, incidents, and complaints.
  • There was clear evidence of action to change services to improve quality.
  • Clinic staff had been called to road traffic accidents on nearby roads, and appropriately trained staff had responded. The service policy did not cover incidents outside of the clinic explicitly.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses. The service was working with IT developers to develop a custom patient information system for the clinic, which would allow searches and audit. The system (which we saw in development) pulled information directly from the British National Formulary to ensure that staff prescribed in line with guidance.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Suggestions were collated and discussed, and there were lots of examples of service improvement as a result.
  • The service had recently formed a patient participation group, as a structured group to discuss service suggestions, feedback and patient needs. Terms of Reference had been agreed and the first meeting was planned.
  • Staff could give feedback, informally and at the quarterly service reviews. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was no evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work. Suggestions from staff, patients and the public were considered and acted upon.