15 November 2022
During a routine inspection
This service is rated as Good. (At the previous inspection in June 2019 the service was rated as Good.)
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 Two Harbours Healthcare Limited in response to concerns identified in inspections of practices within the Primary Care Network (PCN).
This service is registered with CQC under the Health and Social Care Act 2008 in respect 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. At Two Harbours Healthcare Limited services are provided to patients under arrangements made by their own GPs. Therefore, we only inspected the services which are provided by Two Harbours Healthcare Limited.
The chair of the board of directors 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 provided care in a way that kept patients safe and protected from har.
- Services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided.
- Patients received effective care and treatment that met their needs
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- People using the service received a holistic health assessment.
- The provider was aware of the requirements of the duty of candour.
The areas where the provider should make improvements are:
- Review safeguarding training to ensure staff are trained to the appropriate level.
- Review and increase the frequency of appraisal for all staff.
- Continue to embed systems and processes to allow for effective oversight of services, including PCN wide policies and specific operating procedures for pharmacy team members working at external locations.
- Establish systems to ensure staff induction programmes have been reviewed with line managers.
- Review Patient Group Direction processes to ensure these are signed in accordance with guidance.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services