Kaizen Medical Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders encouraged staff to raise concerns when things went wrong. Clinical issues were discussed and learning was shared at staff meetings and through the service’s monthly staff newsletter. Staff told us there was an open culture, and that safety was a top priority. The service had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. For example, following an incident involving a misunderstanding about non-service animals being brought into the clinic, the service introduced clear signage at the entrance outlining its policy. This improved clarity of expectations for people attending the service and improved the overall experience of care.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place to process information about new people using the service and collect necessary safety information. For example, people who used the service completed a medical questionnaire at their initial visit, covering their general health, allergies and next of kin details. People who used the service also completed shorter medical questionnaires before each appointment to provide any health updates to ensure care and treatment remained appropriate.

The service worked with other providers, such as a private dermatology consultant, to deliver shared care. If the service determined, after an assessment, it could not provide direct support, it would offer advice to the person and direct them to more suitable services, or signpost back to their NHS GP.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff had access to up-to-date contact details for external safeguarding teams, such as the local authority, including information on how to contact them during normal working hours and through out-of-hours arrangements when needed. There was a designated safeguarding lead at the service. There was a chaperoning policy in place, and staff had appropriate chaperoning training to undertake this role.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. Staff consulted with people about their requests and proceeded with treatment only when it was in the person’s best interest, carefully documenting and explaining their reasoning to them.

Emergency equipment was available and maintained. Staff had relevant training for dealing with medical emergencies, including basic life support and anaphylaxis. Staff could recognise a deteriorating person and knew of action to take should the need arise during or post-appointment. People who used the service were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to maintain the premises. Fire and health and safety risk assessments had been completed, and identified risks had been addressed. However, we noted the service had 1 fire safety action yet to be completed, relating to the need for the external fire door to open outwards. The service had previously contacted the landlord to resolve this and informed us discussions were ongoing. In the meantime, the service had put clear signage on the door to tell staff and people who used the service which direction it opened. The service had a clear fire evacuation plan and policy, and fire warden training had been completed by all members of staff. Scheduled safety checks were conducted on the fire alarm system, such as, emergency lighting and equipment.

The service had a business continuity plan which included paper documents of policies. Portable appliance testing and equipment calibration had been completed routinely. There were suitable arrangements for the storage of oxygen with correct safety signage displayed.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Safe recruitment processes were followed in line with national legislation. The service’s recruitment and Human Resource (HR) records met the requirements of their policy and Schedule 3 of the Health and Social Care Act 2008. Training, which was deemed mandatory by the service, was up to date, and learning needs and development of staff was managed appropriately. Staff worked within their agreed areas of competence, and these areas were assessed and documented through annual appraisals. Staff received a structured induction, and ongoing support was provided through regular supervisions and annual appraisals.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Cleaning schedules were being followed, and we saw evidence of daily cleaning being undertaken in line with the service’s policy. Leaders reported they also did regular walk-arounds to monitor and audit the standard of cleaning, but these were not being documented. Following our assessment, leaders informed us they would document these moving forward. The facilities and premises were noted to be clean during our onsite visit.

The service had systems to prevent the spread of infection. Spill kits were available, and the service regularly checked they were in date and safe to use if needed. All cleaning items used in the service had appropriate safety sheets to control substances hazardous to people’s health.

All staff had completed relevant infection prevention and control (IPC) training as part of their mandatory training programme and had a good understanding of IPC principles. The service completed 3 monthly hand hygiene observation audits with staff, which checked whether staff followed correct hand hygiene techniques at appropriate points during care and treatment. Staff vaccinations were kept up to date in line with the latest national guidance. Personal protective equipment (PPE) was appropriately stocked and accessible to all staff. The service had clear processes for managing clinical waste. Waste was segregated correctly and disposed of safely in line with current waste management standards.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were involved in planning their medicines, including when changes were made. People knew what to do and who to contact if they experienced unexpected symptoms. The service held appropriate emergency equipment and emergency medicines which were checked regularly.

Staff managed medicines safely, including their storage, administration and recording. Medicines were stored securely and at the correct temperatures. Fridge temperature recordings were taken in line with the service’s cold chain protocol. Waste medicines, including emergency medicines, were recorded and disposed of appropriately. The service completed monthly audits of emergency medicines and overall medicines management in line with its medicines management audit policy. The service had effective systems to manage and respond to safety alerts and medicine recalls.