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Inspection report

Date of Inspection: 23 August 2013
Date of Publication: 18 September 2013
Inspection Report published 18 September 2013 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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 23 August 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

The manager showed us questionnaires that would be sent out to a selection of people who used the service. The questionnaires covered a range of topics such as; the waiting area, cleanliness of the premises, friendly staff and accessibility of facilities. The manager told us they had not yet sent the questionnaires out to people because they wished to increase their patient numbers first. They stated this would ensure people could complete the questionnaires anonymously.

This showed people who used the service would be asked for their views about their care and treatment and their views would be acted upon.

We saw records that showed the provider used audits and had systems in place to monitor the quality of service provided and improve patient care. We saw a number of audits were carried out during the year in accordance with the requirements of the HTM 01-05, and that these were used to inform better practice. Examples of audits carried out were; infection control, radiology, medicines and patient satisfaction. The audits we saw showed good performance against expected standards.

We saw the practice had completed risk assessments covering the environment, water hygiene and legionella. The risk assessments met the requirements as laid out in the HTM 01-05.

We saw clear information was displayed in the waiting room concerning the practices complaints procedure. We were shown the practices complaints policy. We noted there had not been any complaints made for the previous twelve month period; the manager confirmed this to be correct. We saw the practices complaints procedure was clear and noted their procedures would acknowledge, investigate, analyse and take preventative action if complaints were received in the future.

This showed the provider would take account of complaints and comments to improve the service.

We were shown the practices incident and reporting and investigation policy. The manager told us they had not had any incidents or accidents in the previous twelve months. Records we saw confirmed this to be the case.