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Archived: University of Derby Clinical Services Good

Inspection Summary


Overall summary & rating

Good

Updated 8 February 2019

University of Derby Clinical Services is operated by University of Derby. The service has a reception area, separate waiting area and a clinical room containing the dual-energy x-ray absorptiometry machine.

The only service provided by this university was diagnostic imaging, more specifically dual-energy x-ray absorptiometry (DEXA) scanning. We therefore only inspected diagnostic imaging services at this location.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced visit to the service on 11 December 2018. Due to no clinical activity taking place during this unannounced visit, we completed an announced visit to the service on 18 December 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We previously did not have the authority to rate this type of service, however now we do. We rated it as Good overall, but Requires Improvement for well-led.

We found the following areas of good practice:

  • There was a system and process in place for identifying and reporting potential abuse. Staff were supported by individuals with more enhanced training in safeguarding and there were clear channels of escalation which staff were aware of.

  • Clinical environments were visibly clean and tidy, and were suitable and appropriate to meet the needs of the patients who attended for appointments.

  • The scanning environment had appropriate signage in place and staff conducted and recorded regular quality checks of the equipment. There were local rules in place for staff to follow which were written by a suitably qualified radiation protection advisor.

  • Staff conducting the scans had evidence of appropriate, in date radiation safety training.

  • There was a process in place for escalating unexpected and significant findings and staff were able to provide examples of when they had followed this.

  • Feedback from patients and their relatives was positive and we observed some examples of compassionate care.

  • There was evidence of staff working well with multidisciplinary team members both internally and externally, with staff commenting on the good working relationships they had formulated.

  • The service reported low numbers of did not attend appointments and had a process in place for following up patients who failed to attend their appointments.

  • Managers were supportive and visible and staff were confident to approach them if they had concerns to escalate.

  • There was a process in place to identify, assess and manage risks to the service.

However, we also found areas of practice the service needed to improve:

  • During our initial inspection, staff were only mandated to complete regular training on child and adult protection and basic life support. Additional training including infection prevention and control and manual handling was completed as continuing professional development of the practitioner and not recorded by the provider. However, since our inspection the provider has informed us they intend to review the mandatory training requirements of all staff and update any supporting policies for this.

  • The service had not recently conducted any quality assurance audits of the scan reports they were producing. However, information provided following the inspection provided robust actions of how they intended to address this.

  • There was no infection prevention and control policy in place at the service to enable staff to adhere to correct principles and standards. We observed staff not always being bare below the elbow when providing care and treatment, although direct (hands on) patient care was minimal.

  • There were governance systems in place to monitor the quality and sustainable care being provided to patients, however these had failed to identify when audits had not been conducted and when policies and procedures had not been updated to include new regulations, legislation or best practice.

  • There was no system in place to provide translation and interpretation services for patients who did not speak English as their first language.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice for the service to address. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central)

Inspection areas

Safe

Good

Updated 8 February 2019

We rated safe as Good because:

  • There were processes in place to ensure patients were protected from avoidable harm and abuse. Staff knowledge of safeguarding was evident and there were clear processes for escalation.
  • The scanning room was visibly clean and tidy, and staff mainly followed correct infection prevention and control practices when providing care and treatment to patients.
  • The environment was purpose built and had appropriate signage for the level of risk the area posed. All equipment was serviced and maintained appropriately.
  • There was an incident reporting policy and procedure in place which staff were aware of. The service had a positive approach to incident reporting and learning from all incidents.
  • There was a process in place for staff to follow for unexpected and significant findings. Staff were able to provide examples of when they had used this process.
  • There was a strict criteria in place for the patients who were referred to the service and staff reviewed each referral to ensure they met this criteria in accordance with current regulations.

However:

  • The mandatory training structure which was in place at the time of inspection was minimal, with only three areas of training recorded by managers. All other training was considered as a staff’s individual responsibility (including infection prevention and control and manual handling training). Since our inspection, the provider were reviewing their mandatory training processes and will shortly be implementing improvements.
  • Staff were not bare below the elbow at all times when providing care and treatment to patients and there was no infection prevention and control policy to enable staff to adhere to correct infection prevention and control principles.

  • The local rules for the service had not been updated to include the new Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) and Ionising Radiation Regulations 2017 (IRR).

Effective

Updated 8 February 2019

We rated effective as Not rated because:

  • Policies, procedures and guidance was mainly based on the most recent national policies, legislation and best practice guidance including those released by bodies such as National Institute for Health and Care Excellence (NICE).
  • All staff had received a meaningful performance development and review (similar to an appraisal) and there was evidence of professional registration
  • There was evidence of staff working well with multidisciplinary team members both internally and externally, with staff commenting on the good working relationships they had formulated.
  • Staff were knowledgeable about the Mental Capacity Act (2005) and the requirements around consent.

However:

  • The service had not undertaken any scan report audits for 22 months due to changes in staffing and external support. This was identified by the provider during our inspection, and information was submitted post inspection of how they planned to address this.

Caring

Good

Updated 8 February 2019

We rated caring as Good because:

  • Patients we spoke with were all positive about the service they received and the staff who provided the service. Our own observations during the inspection supported positive interactions between staff and patients.
  • There were systems in place for the service to collect patient satisfaction and feedback on a regular basis.
  • Staff ensured patients received information about their scan and gave them the opportunity to ask questions.

Responsive

Good

Updated 8 February 2019

We rated responsive as Good because:

  • Staff at the service had made a concerted effort to meet the needs of patients living with dementia, including completing additional dementia awareness training.

  • The service reported very low numbers of did not attend appointments, however there was an assured process in place to manage patients who failed to attend their appointments.

  • The service had a positive approach to the complaints they received (which was low in numbers) and the management of complaints.

  • The referral to scan time was routinely between two to three weeks, which was well below the average time for an acute provider.

  • During the reporting period of October 2017 to September 2018 there were no cancellation of appointments for non-clinical reasons.

However:

  • There were no formal processes in place to meet the needs of patients who did not speak English as their first language, despite staff telling us they had previously scanned patients who required translation services.

  • The service had only just formally started to record the number of did not attend appointments each month.

Well-led

Requires improvement

Updated 8 February 2019

We rated well-led as Requires improvement because:

  • The governance systems in place were not robust enough to identify policies and procedures which contained references to outdated regulations, legislation and best practice or a lack of scan report audits since the change in Radiation Protection Advisors.

  • There were processes in place to identify, record and assess risks in the service including a University risk register. However no risks were recorded on there which were specific to the scanning department despite some risks being identified by inspectors and an additional risk of sustainability of services being identified by the staff from the service at the time of inspection.

  • At the time of our inspection, the managers had minimal oversight of some aspects of the clinical setting and staff training, including mandatory training completion, infection prevention and control practices and lack of quality audits.

  • There was no vision or strategy for the service at the time of our inspection, although it was acknowledged other factors were impacting on this.

However:

  • There was evidence of information and issues being escalated upwards, as well as information being cascaded downwards through the system.

  • There was a positive culture within the service with all staff saying they supported and respected each other, and leaders were visible and approachable.

  • There was an open and honest culture within the service with a no blame approach to incidents and investigations of incidents.

  • There was evidence of patient engagement and feedback systems were in place to enable service improvements to be made.

Checks on specific services

Diagnostic imaging

Good

Updated 8 February 2019

Diagnostic imaging, more specifically the provision of dual-energy x-ray absorptiometry (DEXA) scanning was the only service provided at this location. We rated this service as good overall with requires improvement for well-led because patients were protected from avoidable harm and abuse. Care and treatment was provided based on best practice and provided by competent staff. Feedback from patients was positive and we ourselves observed positive examples of compassionate care. Patients could access care and treatment in a timely way. However, we were not assured that the governance systems in place were robust enough to safeguard high quality care and improve service quality.