CJA Medical

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

Safe – this means 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 Requires Improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 service.

Staff were encouraged to raise concerns when things went wrong. Staff told us incidents, ‘near misses’ and complaints were shared, investigated and discussed during regular staff meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes to record, investigate and take action from incidents and complaints. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in reflections and changes that improved care for people.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place for processing information relating to new people using the service as well as care and treatment records shared with the person’s registered NHS GP with consent. Referrals and results were managed in a timely way. During our on-site visit, we noted clinical records contained baseline measurements prior and during treatments and people were referred to the person’s NHS GP where required. There were pathways to ensure any skin lesions or suspected cancer was appropriately referred to a local dermatologist and the person’s NHS GP for further monitoring.

The service did not always work well with people to understand what being safe meant to them and how to achieve that. However, the service provided examples of how they worked with healthcare partners such as people’s NHS GP which focused on improving people’s lives or protecting their right to live in safety, avoidable harm and neglect.

During our on-site visit, staff told us they had previously carried out chaperoning duties, but the service had not implemented a specific policy relating to chaperoning arrangements, including outlining guidance for staff. This was despite the service’s safeguarding policy stating a separate chaperoning policy was available. This meant there were risks which compromised safety, including potential reputational damage to clinicians without the appropriate guidance in place for staff. However, there was a mixture of clinical and non-clinical staff members, who had chaperone responsibilities as part of their role. Those staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

In addition, leaders told us how people who were vulnerable were supported to ensure their treatment remained appropriate. This included follow-up communication provided to people’s NHS GP practice. We reviewed a sample of people’s records, and these demonstrated how the service assessed mental capacity and how registration forms were used to support the overall review of people’s health. The service shared concerns quickly and appropriately with appropriate healthcare providers. There were designated safeguarding children and adult leads at the service.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating person and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened. Clinical staff were trained in basic life support and anaphylaxis and were equipped to deal with pre-hospital immediate care.

People who had higher risk health considerations such as newly registered people (due to unrecorded health information and unknown medical history prior to consultation) were booked into appointments where lone working did not take place.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, the service was unable to provide a dedicated fire safety policy detailing fire arrangements across the building or for the service. These included details relating to trained fire wardens or schedules relating to maintaining equipment such as fire extinguishers, fire alarm servicing and emergency lighting. The service was also unable to provide evidence of a fire risk assessment relevant to the areas of the building used by the service. This meant the service was unable to demonstrate that the premises was safe or that it met its obligations under the Fire Safety Act 2021. However, we observed some fire safety measures in place such as documented fire alarm testing; fire extinguisher servicing and Portable Appliance Testing (PAT) of equipment used by the service.

The service had also not retained and stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all cleaning products stocked or used by the contracted cleaner, alongside Safety Data Sheets (SDS). This posed a health and safety risk for staff without guidance of usage and what to do in the case of incidents to evaluate the specific risks associated with how that substance is used in the workplace. After the on-site visit, the service immediately rectified the issue and provided evidence to demonstrate it had COSSH risk assessments and SDS for all products stocked.

However, contracts were in place to ensure the premises was maintained and a business continuity plan was monitored and reviewed.

The service did not always make sure staff were trained in line with service policy and national guidelines. During the on-site visit, staff told us they had previously carried out chaperoning duties. However, staff had not completed chaperoning training, and the service had not classified this training as mandatory, despite chaperoning being routinely undertaken. When we spoke to staff, they were unclear on how to undertake this role safely. This meant staff were unequipped to act as an independent and effective witness, therefore increasing the risk of people not receiving safe support during intimate examinations.

However, the service made sure there were enough qualified staff employed to carry out both clinical and administrative roles. All recruitment and Human Resource (HR) records were kept in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 2 members of staff and information was available and up to date in line with service policy.

Staff worked together to provide safe care and treatment that met people’s individual needs. Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe service was mitigated and prevented lone working.

The service did not assess or manage the risk of infection. They did not detect and control the risk effectively. For example, the service did not have a dedicated infection prevention and control policy to outline training requirements; cleaning procedures; audit schedules and appendices such as templates for staff guidance and usage. This meant there were unclear arrangements and guidance for staff to maintain standards of healthcare cleanliness and infection control processes. Although we noted the premises to be clean during the on-site visit, there were no records in place to demonstrate cleaning arrangements of the environment to maintain oversight. In addition, there had been no infection control audits completed to assess and monitor cleaning standards. The service told us previous randomised hand hygiene audits had been carried out but this had not been completed in the last 12 months.

The service had not assessed and mitigated the risks related to legionella bacteria. The service had ineffective systems to assess legionella bacteria risk and uphold cleaning standards. The service was also unable to demonstrate monitoring of water temperature sampling for each room to determine water temperatures were controlled to prevent the growth of legionella bacteria in line with national guidelines. In addition, the service was unaware of any arrangements to ensure regular water flushing took place. During the on-site visit, we were told a legionella bacteria service assessment had been booked to take place. However, prior to this, it was unclear whether a previous assessment had determined the legionella status of the premises and staff could not verify any previous servicing arrangements. This increased the likelihood of preventable exposed health risk to people as without an effective process, a bacterial outbreak may not be detected until people had already reported ill-health.

Clinical waste arrangements were also not effective to ensure safe storage in line with infection prevention and control national guidelines. In particular, the outdoor clinical waste bin was not securely locked to prevent potential misuse. Sharps injury posters had not been displayed in all clinical rooms where these procedures take place from. After the on-site visit, the service provided evidence this had been rectified to mitigate the risk of preventable harm.

However, all staff had had received relevant training in relation to infection prevention and control (IPC). During the on-site visit, the service presented a cold chain policy, waste management policy and sharps injury policy which staff demonstrated awareness of.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Although the service maintained cold chain processes and fridges used to store medicines were temperature monitored through an alarm system. Records did not state the actual temperature as observed by the recorder, in line with national guidance. This meant the service was unable to demonstrate what temperatures the fridges were and therefore be able to determine the appropriate action when fridge temperatures were outside of safe ranges. We raised this with leaders, who told us due to the limited stock of medicines in the fridge, these were simply disposed of when temperatures exceeded safe ranges, when they were alerted by the alarm.

Medicines were stored securely and the service held appropriate emergency equipment and emergency medicines which were checked regularly, and staff were aware of procedures for raising urgent concerns. However, there was no documented risk assessment for determining the selection of medicines based on the service’s scope of treatment and procedures, in line with national guidelines. Leaders told us this would be reviewed as part of an improvement plan, but we were unable to verify implemented changes at this assessment.