This practice 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 Cheshunt Minor Injuries Unit on 9 November 2022 as part of our inspection programme. This was the first inspection undertaken at this service since it was registered with this provider.
There was no Registered Manager in place at the time of inspection due to recent changes in staff management, however the provider had submitted applications to update their registration and these applications were in progress. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Our key findings were:
- There were clear systems to keep people safe and safeguarded from abuse.
- There were clear and effective processes for managing infection prevention and control.
- The service had systems for appropriate and safe handling of medicines, however joint processes in place for administering medicines without prescriptions required strengthening.
- The provider had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The provider 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 service used key performance indicators to monitor performance and improve outcomes for people.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- The service organised and delivered service to meet patients’ needs.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- The way the service was led and managed promoted the delivery of high-quality, person-centred care.
- Leaders and staff had a commitment to improve.
The areas where the provider should make improvements are:
- Improve induction monitoring processes for temporary and permanent staff.
- Maintain sufficient staffing levels to deliver safe care and treatment.
- Continue working with partner organisations in taking action to reduce health, safety and security risks.
- Continue with plans to develop, implement and monitor locally owned Patient Group Directions.
- Strengthen systems and processes with partner organisations to ensure clear responsibilities, roles and systems of accountability for staff.
- Review ways to ensure staff have a clear understanding of and contribute to the vision and strategy of the service.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services