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Inspection report

Date of Inspection: 20 September 2012
Date of Publication: 30 October 2012
Inspection Report published 30 October 2012 PDF | 77 KB

People should be cared for in safe and accessible surroundings that support their health and welfare (outcome 10)

Meeting this standard

We checked that people who use this service

  • Are in safe, accessible surroundings that promote their wellbeing.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 20 September 2012 and talked with staff.

Our judgement

Staff and visitors were protected against the risks of unsafe or unsuitable premises.

Reasons for our judgement

There were no facilities for patients as they were not required to attend the laboratory.

The provider had taken steps to provide an environment that was suitably designed and adequately maintained. In accordance with the provider’s quality statement we found that the pathology laboratory had been purpose built. Access to the laboratory was limited to authorised personnel only. All areas were keypad controlled. This demonstrated that appropriate measures were in place to ensure the security of the premises.

The premises were located on the site of another organisation. We saw how there was an agreement with that organisation to enable them to carry out internal audits of the laboratory by a suitably trained assessor who was familiar with the requirements of the Clinical Pathology Accreditation (CPA), which is part of the United Kingdom Accreditation Service (UKAS).

CPA is a voluntary scheme and participants are inspected every four years and have to confirm each year that they are continuing to operate according to strict guidelines.

The laboratory had received accreditation from CPA when it was part of a previous organisation until March 2012. The current registered provider of the laboratory provided us with records that demonstrated they had appropriately notified the CPA of the changes in ownership. A review of the laboratory to meet the required criteria for the accreditation was imminent. The manager of the laboratory told us they had continued to meet the required standards since the change in ownership.

We saw records of the last health and safety audit undertaken in December 2012. Appropriate action plans had been put in place to ensure any areas for improvement were addressed.

We identified that the provider had arrangements in place to meet the Control of Substances Hazardous to Health Regulations 2002. There were documents available that showed how risks created by work with substances hazardous to health were assessed and appropriate control measures were in place. There was use of the appropriate containment level for the biological agents likely to be encountered.

We saw how accidents and incidents were monitored by the manager. The manager told us they were aware of the reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR), which requires employers to report specified accidents, dangerous occurrences and cases of ill health to Health and Safety Executive.

We saw how the laboratory had standard operating procedures (SOPs) for the general work of the laboratory and for each diagnostic procedure carried out. These identified safe working practices to control any risks.

All safety precautions were in place and tested with regard to all specialist equipment. We saw that equipment was checked daily to indicate the precision and performance. In addition an external quality assurance team checked the performance of the equipment at least monthly.

There were suitable rest rooms for staff and secure areas for personal effects.