21 Jan to 21 Jan 2019
During a routine inspection
This service is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Unit 4 on 21 January 2019 as part of our inspection programme.
At this inspection we found:
- The service had systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
- The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- The management and administrative system for recording the provider’s mandatory training was not up to date and indicated gaps in training completion. The service was unable to fully evidence training completion.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Patients were able to access care and treatment from the service within an appropriate timescale for their needs. At times when service demand was high regional escalation plans were implemented and external organisations keep abreast of performance and risk.
- Views and experiences of people who used the service was limited. This meant they had limited opportunity to actively engage in shaping the service.
- There was a focus on continuous learning and improvement at all levels of the organisation. However, we found limited evidence to support testing of new learning was embedded.
The areas where the provider should make improvements are:
- Consider a formal system to demonstrate evidence of how learning from incidents and quality improvement work has been embedded and improved quality of care delivery.
- Continue to develop the programme of completed audits to identify impact on patient care.
- Systems to demonstrate completion of one to one monthly reviews and training records should be maintained for all staffing groups to enable oversight from the leadership team.
- Continue to improve opportunities to engage the views and experiences of service users including carers and people in a range of equality groups.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice