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Inspection Summary


Overall summary & rating

Updated 26 March 2018

We carried out an announced comprehensive inspection on 25 January 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Prior to our inspection patients were asked to complete comment cards telling us about their experiences of using the service. Sixteen people provided wholly positive feedback about the service.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved.
  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Services were provided to meet the needs of patients.
  • Patient feedback for the services offered was consistently positive.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Updated 26 March 2018

We found that this service was providing safe care in accordance with the relevant regulations.

  • There was an effective system for reporting and recording significant events and sharing lessons to make sure action would be taken to improve safety.
  • There were systems in place so that when things went wrong, patients could be informed as soon as practicable, receive reasonable support, truthful information, and a written apology, including any actions to improve processes to prevent the same thing happening again.
  • The service had clearly defined and embedded systems, processes and practices to minimise risks to patient safety.
  • Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
  • The service had adequate arrangements to respond to emergencies and major incidents.

Effective

Updated 26 March 2018

We found that this service was providing effective care in accordance with the relevant regulations.

  • Staff were aware of and used current evidence based guidance relevant to their area of expertise to provide effective care.
  • Staff had the skills and knowledge to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • The service had effective arrangements in place for working with other health professionals to ensure quality of care for the patient.
  • Staff sought and recorded patients’ consent to care and treatment in line with legislation and guidance.

Caring

Updated 26 March 2018

We found that this service was providing caring services in accordance with the relevant regulations.

  • The service had systems and processes in place to ensure that patients 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 accessible.
  • We saw systems, processes and practices allowing for patients to be treated with kindness and respect, and that maintained patient and information confidentiality.
  • Feedback we received from patients was wholly positive about the service.

Responsive

Updated 26 March 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain and provide feedback was available and there was evidence systems were in place to respond appropriately and in a timely way to patient complaints and feedback.
  • Treatment costs were clearly laid out and explained in detail before treatment commenced.

Well-led

Updated 26 March 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had a clear vision to deliver high quality care for patients.
  • There was a clear leadership structure and staff felt supported.
  • The service had policies and procedures to govern activity and held regular governance meetings.
  • An overarching governance framework supported the delivery of high quality care. This included arrangements to monitor and improve quality and identify risk.
  • Staff had received inductions, performance reviews and up to date training.
  • The provider was aware of and had systems in place to meet the requirements of the duty of candour.
  • There was a culture of openness and honesty. The service had systems to alert them to notifiable safety incidents and to share the information with staff and ensure appropriate action was taken.
  • The service had systems and processes in place to collect and analyse feedback from staff and patients.