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Archived: Marie Stopes International Birmingham

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 10 January 2014
Inspection Report published 10 January 2014 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 10 December 2013, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff, reviewed information given to us by the provider, were accompanied by a pharmacist and reviewed information sent to us by commissioners of services.

Our judgement

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

Reasons for our judgement

People who used the service were asked for their views about their care and treatment and they were acted on. Every person who attended the centre was given a questionnaire to complete about the service they had received. We noted there was a 'red alert' system which identified any negative feedback. All red alerts had to be investigated by the registered manager and reported back to the provider.

A quarterly report on the completed questionnaires was compiled and returned to the clinic by the provider. The report contained the results of all the UK Marie Stopes International centres, so the Birmingham centre was able to compare their performance against other centres in the company. We were shown the last report received by the centre. Feedback from people who used the service showed that the overall satisfaction rating was at 94%. The centre had received a low satisfaction rate regarding people not always being informed of delays. The manager told us about the actions taken to improve this and that negative comments in relation to this issue had reduced. During our visit, the three people we spoke with did not raise any concerns regarding delays. One person told us, “I did not have to wait long for my appointment today”.

A log of incidents was maintained. Serious incidents were investigated so that the 'root causes' of the incident were identified. We saw that investigations also identified areas where the clinic could improve. We looked at one investigation report and checked to make sure the recommended actions had been implemented. The provider may find it useful to note that we found that one of the actions had not been completed within the timescale given. The manager had told us the action was a corporate action and they would contact the person concerned to ensure it was completed.

We found that the registered provider had quality monitoring arrangements in place. An audit had been completed in May 2013 by the provider's quality assurance team to assess if the clinic was meeting essential standards of quality and safety. We found the audit had not identified any significant concerns. We saw there was also programme of regular internal audit. The audits identified shortfalls and there was clear evidence that these were followed up routinely to monitor improvements.

We saw minutes of an Integrated Governance Committee meeting. These showed that senior management convened to discuss all matters relating to the service. The meetings covered such areas as risk management, incidents and transfers, infection prevention, health and safety and results from the client satisfaction survey. We noted that the minutes reported that the service had not been reporting some incidents to the provider and that this had been rectified. This showed that the provider's systems for monitoring quality and safety were effective.

The provider took account of complaints and comments to improve the service. Arrangements were in place so that people could raise any concerns that they had about the service they received. The provider showed us their complaints register which showed that they had received five complaints in 2013. We sampled two of the complaints received. People's complaints were fully investigated and resolved where possible to their satisfaction.

The manager told us that in response to some comments from people using the clinic there were proposals to alter the environment. This was dependant on the building structure and lease conditions permitting the changes. If completed, these changes to the building will enable people to have their partner stay with them for part of their patient pathway, should they wish.

There were appropriate fire precautions in place. Fire risk assessments and regular audits of fire safety had taken place. The fire log demonstrated that regular checks took place of fire-fighting equipment and there were regular fire drills.