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English Institute of Sport - Bisham Abbey Good

Inspection Summary

Overall summary & rating


Updated 1 May 2020

We carried out an announced comprehensive inspection at English Institute of Sport - Bisham Abbey as part of our inspection programme.

The employed doctors provide routine sports medicine consultations for both injury and illness to elite athletes. Athletes are nominated by various sport and athletics national governing bodies of sport to receive care. 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 general exemptions from regulation by CQC which relate to particular types of service and these are set out in of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The services provided at this location which are not in scope include: physiotherapy and psychological therapies such as counselling.

The location has a registered manager in place. 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.

CQC comment cards were used to gather patient feedback. We received seven comment cards and they all contained highly positive feedback about the support and care provided by the service.

You can see full details of the regulations not being met at the end of this report.

Our key findings were:

  • The provider had systems to monitor safety and take action where risk was identified.
  • The premises were safe and suited to the provision of care.
  • When incidents occurred which required reviews, any learning was implemented.
  • Diagnostic procedures were undertaken appropriately and based on relevant guidance.
  • Patients were informed of their choices and implications of medical interventions.
  • Consent was sought prior to interventions. However, staff had not received the appropriate awareness training on obtaining consent from patients under 16 years of age.
  • Staff received training in a broad range of subjects related to the provision of care. However, infection control training was not provided.
  • Patient feedback showed staff were caring and considerate.
  • Patients were able to receive diagnostics quickly when they required them.
  • There were governance arrangements in place for clinical and non-clinical aspects of the service.
  • There was a positive culture among staff.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure staff receive relevant support, training and professional development necessary to enable them to carry out the duties they are employed to perform.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 1 May 2020

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, such as fire safety 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.
  • 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 had acted on concerns related to safeguarding and potential abuse.
  • 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).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. The provider was reviewing the level of safeguarding adult training required for the doctors providing services.
  • Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. However, not all staff had received infection control training.
  • 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. This included periodic checks of equipment and premises and notes of any actions taken to maintain safe provision of services were included in the ongoing assessment.

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.
  • There was an effective induction system for staff tailored to their role.
  • Staff received training on how to manage emergencies and to recognise those in need of urgent medical attention.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.
  • There were appropriate indemnity arrangements in place

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 undertake diagnostics was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies where necessary. We saw that patients’ GPs were contacted when required.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • Equipment used for the purpose of diagnostics was stored and handled safely.
  • No medicines were used for the purposes of diagnosing patients.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • A traffic light coding system was used for any outbreak of infections which may affect patients and staff and this coding system was used to determine what action was taken to reduce the risk of cross contamination.

Lessons learned and improvements made

The service learned 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. Meetings were undertaken within the location to review learning and incidents were escalated to the provider at headquarters for external reviews.
  • The reporting system and culture within the service enabled and ensured compliance with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty.


Requires improvement

Updated 1 May 2020

The provider had not considered all the training requirements required by staff. This included elements of awareness regarding consent and infection control.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice.

  • Patients’ diagnostic and screening 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.
  • Ongoing assessments were communicated with other professionals such as GPs.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements.
  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.
  • We looked at audits on vitamin D deficiency and diagnosis and an ongoing audit of patient record keeping. We saw that the vitamin D audit had contributed to the services protocol related to identifying and treating the deficiency of the vitamin.
  • The record keeping audit provided a regular review of accurate and appropriate record keeping.

Effective staffing

The provider had not ensured all staff had the skills, knowledge and experience to carry out their roles safely .

  • All staff were appropriately qualified and checks were made to ensure doctors were registered with professional bodies and revalidation was supported by the provider.
  • The provider had an induction programme for all newly appointed staff.
  • The provider understood most of 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.
  • There was no training provided periodically to ensure staff had infection control training and all the elements of training related to consent to care which might be required in order to ensure patients’ rights. This may include the Gillick competency (gaining consent from patients under 16 years old) and the Mental Capacity Act (2005). Supporting policies were available but these did not ensure staff were aware of when to refer to such guidance in order to ensure patients were always protected from harm and that their rights were always considered. 

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, such as GP practices.
  • All patients were asked for consent to share details of their consultation and any diagnostics with their registered GP on each occasion they used the service.
  • Patient information was shared appropriately internally (this included when patients moved to other professional services), and the information needed to plan and care following any diagnosis was available to relevant staff.

Supporting patients to live healthier lives

Staff had means of supporting patients 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. For example, exacerbations of long term conditions identified in the service were communicated with GPs.
  • 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 but not all training was provided in line with legislation and guidance .

  • Training requirements for staff did not include all the requirements within legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions and provided information so they could make informed decisions.



Updated 1 May 2020

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of care and service patients received via feedback forms. This was a new initiative and therefore there was no data output to analyse.
  • Feedback from patients was positive about the way staff treat people. Seven CQC comment cards completed were positive about the services received.
  • Individual doctors’ feedback was used to assess care provided.
  • 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.

  • Staff informed us interpretation services would be made available for patients who did not have English as a first language.
  • Patients told us through comment cards, that they felt listened to and supported by staff.

Privacy and Dignity

The service respected/did not respect patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Consultations were undertaken in private consultation rooms where necessary.



Updated 1 May 2020

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. For example, clinicians were available at short notice to provide patients with assessments of their needs.
  • 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. The service manager explained that when patients had specific needs due to disability or communication requirements, the serviced assessed these and planned how to enable them to access the service.

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 and diagnosis.
  • Patient comment cards were complimentary about access to the service.

Listening and learning from concerns and complaints

The service had a system to investigate and respond to complaints and concerns.

  • Information about how to make a complaint or raise concerns was available.
  • The service had a complaint policy and procedures in place.
  • No complaints had been made in order for us to review the operation of the policy.



Updated 1 May 2020

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.
  • Staff told us leaders at were approachable and worked with them to make sure there was an inclusive culture.

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 in terms of service delivery.
  • Staff displayed a positive vision which was highly supportive of patients.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.


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

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents. 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. All staff received regular appraisals. However, some training needs were not identified and delivered.
  • Staff were supported to meet the requirements of professional revalidation where necessary.

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.
  • Staff were clear on their roles and accountabilities
  • There were effective policies and procedures in place.

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 risks.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit and appraisal.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place for major incidents.

Appropriate and accurate information

The service acted on accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality of care and services was discussed in relevant meetings where all staff had sufficient access to information.
  • There were robust arrangements to ensure data was kept securely and confidentially.

Engagement with patients, the public, staff and external partners

The service involved patients, 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. For example a comments box had been installed for staff and patients to provide feedback.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents.
  • 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. For example there had been a system to identify and act proportionately to risks related to infection outbreaks.