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St Ives House Good Also known as East Lancashire Medical Services

Inspection Summary

Overall summary & rating


Updated 11 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Ives House (East Lancashire Medical Services Limited) on 6 March 2017. The overall rating for the practice was good, although the key question of safe was rated as requires improvement. A requirement notice was issued in relation to safe care and treatment, as the provider was found to be in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for St Ives House on our website at

This inspection was a desk-based review carried out on 6 September 2017 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 6 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the service is rated as good, with the previous rating of requires improvement for the key question of safe updated to a rating of good.

Our key findings were as follows:

  • The service had made improvements to how it documented mandatory training undertaken by sessional staff.

  • All staff had been reminded who could undertake chaperone responsibilities, and the service’s chaperone policy had been updated to make this more explicit.

  • Staff who drove as part of their role had been reminded that relevant health checks were available to them as part of their employment with the service.

  • The service’s incident reporting policy had been updated to ensure it incorporated incidents being investigated following complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas



Updated 11 October 2017

At our previous inspection on 6 March 2017, we rated the practice as requires improvement for providing safe services. While we found that staff were aware of their responsibilities with regards to safeguarding vulnerable adults and children, evidence showed that the service had not consistently obtained assurance that clinical staff working on a sessional basis had completed the appropriate training in this area. This was also the case with other topics of training, such as basic life support. Some of the staff we spoke with during the inspection told us they carried out chaperone duties, but had not received training for this role.

The service was able to demonstrate these arrangements had improved when we undertook a desk top review of these issues on 6 September 2017. The service is now rated as good for providing safe services.

  • Training records had been updated demonstrating appropriate life support and safeguarding training had been completed by sessional clinical staff.

  • We were given assurance that driver safety and fitness tests were available to navigators, and were shown training records demonstrating that these had been completed.

  • Information had been thoroughly cascaded to both non clinical and clinical staff clarifying which staff could act as chaperones.

  • The service’s incident reporting policy had been updated and meeting minutes were provided demonstrating how both complaints and incidents were discussed at regular senior management team meetings to ensure learning from these was implemented.



Updated 10 July 2017

The service is rated as good for providing effective services.

  • The service was consistently meeting National Quality Requirements (performance standards) for GP out-of-hours services to ensure patient needs were met in a timely way.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Clinicians provided urgent care to walk-in patients based on current evidence based guidance.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.



Updated 10 July 2017

The service is rated as good for providing caring services.

  • Feedback from the large majority of patients through our comment cards and collected by the provider was very positive.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality. However, the privacy in the reception area at the Burnley Urgent Care Centre was not always well managed during our visit.

  • Patients were kept informed with regard to their care and treatment throughout their visit to the out-of-hours service.



Updated 10 July 2017

The service is rated as good for providing responsive services.

  • Staff reviewed the needs of its local population and engaged with its commissioners to secure improvements to services where these were identified.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • The service had systems in place to ensure patients received care and treatment in a timely way and according to the urgency of need.
  • Information about how to complain was available and easy to understand and evidence showed the service responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.



Updated 10 July 2017

The service is rated as good for being well-led.

  • The service had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The service had a number of policies and procedures to govern activity and held regular governance meetings. However, we found staff working the evening shifts could not always access these with ease.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The provider encouraged a culture of openness and honesty. The service had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
  • The service proactively sought feedback from staff and patients, which it acted on.
  • There was a strong focus on continuous learning and improvement at all levels.