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Chenies Mews Imaging Centre Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 May 2019

Chenies Mews Imaging Centre is operated by QS Enterprises Ltd. The service provides Magnetic Resonance Imaging (MRI) diagnostic services for young people and adults.

We inspected the MRI diagnostic facilities using our comprehensive inspection methodology. We carried out an unannounced visit to the hospital on 1 November 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 service understood and complied with the Mental Capacity Act 2005.

The main service provided by Chenies Mews Imaging Centre was MRI scanning.

Services we rate

This was the first inspection of this service. We rated it as Requires improvement overall.

We found the following issues the service needed to improve:

  • The service did not have robust policies, procedures and processes in place to ensure children were protected from abuse and improper treatment.
  • Staff kept themselves, equipment and the premises clean, but hand hygiene compliance was variable.
  • Staff completed risk assessments for each patient. However, local emergency procedures for cardiac arrest were not being followed.
  • The service did not always follow best practice when prescribing, giving and storing medicines.
  • Staff recognised incidents and reported them. However, the provider had two systems for reporting incidents but it was not clear how learning from these, was shared or how practice was reviewed.

  • The service did not reference the National Institute for Health and Care Excellence (NICE) guidance or other national guidelines in policies procedures and guidelines, the.
  • The service had an audit schedule, but there was no formal peer review audit undertaken by Chenies Mews Imaging Centre or follow up where areas of non-compliance has been identified.

  • The service’s consent policy did not reference how staff should seek consent from children and young people under the age of 18 years of age.
  • The service treated concerns and complaints seriously but Information on complaints was not available at the service or easily assessible on the provider’s website.
  • The service did not have a systematic programme of clinical audit to monitor quality or systems to identify where action should be taken.
  • The service did not have effective systems for identifying risks, planning to eliminate or reduce them.

However, we also found the following areas of good practise.

  • The service provided mandatory training in key skills to staff.
  • The service had suitable premises and equipment.
  • The service made sure all staff were competent for their roles.
  • All staff worked together as a team to benefit patients
  • Staff treated patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them about their care and treatment.
  • The service was planned and designed to meet the needs of the patients as it gave them access to timely scans.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it.
  • The staff understood the vision and strategy of the service. Staff felt supported and were positive about their leaders.
  • There were plans to extend the service and ensure sustainability.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Inspection areas

Safe

Requires improvement

Updated 21 May 2019

We rated safe as Requires improvement because:

  • The service did not have robust policies, procedures and processes in place to ensure children were protected from abuse and improper treatment.
  • Staff kept themselves, equipment and the premises clean, but hand hygiene compliance was variable.
  • Staff completed risk assessments for each patient. However, resuscitation simulations were not being undertaken every month.
  • The service did not always follow best practice when prescribing, giving and storing medicines.
  • The service recognised incidents and reported them. However, the provider had two systems for reporting incidents but it was not clear how learning from these, was shared or how practice was reviewed.

However, we also found the following areas of good practise.

  • The service provided mandatory training in key skills to staff.
  • The service had suitable premises and equipment.

Effective

Updated 21 May 2019

We do not currently rate of effective for diagnostic imaging.

  • The service did not reference the National Institute for Health and Care Excellence (NICE) guidance or other national guidelines in policies procedures and guidelines, the service had an audit schedule, but there was no formal peer review audit undertaken by Chenies Mews Imaging Centre or follow up where areas of non-compliance has been identified.
  • The service’s consent policy did not reference how staff should seek consent from children and young people under the age of 18 years of age.

However, we also found the following areas of good practise.

  • The service made sure all staff were competent for their roles.
  • All staff worked well together as a team to benefit patients.

Caring

Good

Updated 21 May 2019

We rated caring as Good because:

  • Staff treated patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to patients to minimise their distress.

  • Staff involved patients and those close to them about their care and treatment.

Responsive

Good

Updated 21 May 2019

We rated responsive as Good because:

  • The service was planned and designed to meet the needs of the patients as it gave them access to timely scans.

  • The service took account of patients’ individual needs.

  • People could access the service when they needed it.

However, we also found the following issue that the service provider needs to improve:

  • The service treated concerns and complaints seriously but Information on complaints was not available at the service or easily assessible on the provider’s website

Well-led

Requires improvement

Updated 21 May 2019

We rated well-led as Requires improvement because:

  • The service did not have a systematic programme of clinical audit to monitor quality or systems to identify where action should be taken.

  • The service did not have effective systems for identifying risks, planning to eliminate or reduce them.

However. we also found the following areas of good practise.

  • The staff understood the vision and strategy of the service. Staff felt supported and were positive about their leaders.
  • There were plans to extend the service and ensure sustainability.
Checks on specific services

Diagnostic imaging

Requires improvement

Updated 21 May 2019

QS Enterprises Ltd. The service provides Magnetic Resonance Imaging (MRI) diagnostic services to adults, children and young people.