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

Inspection Summary


Overall summary & rating

Updated 26 July 2018

We carried out an announced comprehensive inspection on 16 May 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The provider offers face to face consultation, examination and treatment for the management of pain for adults over the age of eighteen.

We received feedback from 17 patients who used the service; all were positive about the service experienced. Many patients reported that the service provided high quality care.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • Information on how to complain was available and easy to understand.
  • There was a focus on learning and improvement.

There were areas where the provider could make improvements and should:

  • Review service procedures to ensure patient identity is checked before treatment.

  • Review process for recording patient records so they are available in English for continuity of care.
  • Review procedures in place for communication with patients’ NHS doctors where appropriate.
  • Review service procedures for staff training.
  • Review service procedures to maximise the benefits of quality improvement activity.
  • Review options to make reasonable adjustments to improve access to the service.
Inspection areas

Safe

Updated 26 July 2018

We found that this service was providing safe care in accordance with the relevant regulations.

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • Staff knew how to recognise the signs of abuse and how to report concerns.
  • The service had a business continuity plan in place.
  • The service did not undertake regular fire drills.
  • Premises and equipment were clean. The service had not acted on one of the issues they had identified in their infection control audit.
  • The service did not always maintain patient records in English.
  • The service did not have a system in place to verify patients’ identity during registration.

Effective

Updated 26 July 2018

We found that this service was providing effective care in accordance with the relevant regulations.

  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • There was evidence of quality improvement and the service had undertaken clinical audits; however, the audits were not written up to support learning.
  • There was evidence of appraisals for staff.

Caring

Updated 26 July 2018

We found that this service was providing caring services in accordance with the relevant regulations.

  • Staff treated patients with compassion, kindness, dignity and respect.
  • The Care Quality Commission comment cards we received were all positive about the service experienced. Many patients reported that the service provided high quality care.

Responsive

Updated 26 July 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • Information on how to complain was available and easy to understand.

Well-led

Updated 26 July 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had a vision to deliver high quality care and promote good outcomes for patients.
  • There was a clear leadership structure and staff felt supported by management. The service had policies and procedures to govern activity and held regular governance meetings.
  • Staff had received inductions, annual performance reviews and attended staff meetings and had training opportunities.
  • The provider was aware of the requirements of the duty of candour.
  • The service kept complete patient care records which were clearly written or typed, and these were stored securely. However, we found the patient records were not always maintained in English to enable continuity of care.