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Archived: Filton Blood Centre

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Inspection report

Date of Inspection: 28, 29 January 2014
Date of Publication: 5 March 2014
Inspection Report published 05 March 2014 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 28 January 2014 and 29 January 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and reviewed information given to us by the provider.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

We spoke to donors in both the blood centre and the mobile blood donor session. They told us “We have been given the donor helpline telephone number if we want to make comments about the service”, “At the end of every session we are asked if there are any comments we want to make”, “I see there are some comment cards on the table (mobile donor session) but I don’t feel I need to complete one” and “Everything seems to work like clockwork and procedures are well thought out”.

Comments made on donor satisfaction survey forms were reviewed by the centre manager and discussed with the team staff. Good feedback was collated and fed back to the team staff and this was confirmed by those donor carers we spoke with. A discussion would be had with any donor who had made comments that required a response. Any information received by the national contact centre was responded to within five working days, by the relevant manager and any corrective and preventative actions were taken.

Staff surveys were completed on an annual basis. The results from the 2013 survey had not been collated by NHS Blood and Transplant, but we looked at the outcome of the 2012 survey. This showed what things the service had improved on, and where the areas for improvement were. As a result of the survey the top three priorities were identified along with actions plans on how the improvements were going to be achieved. Donor carers and qualified nurses we spoke with confirmed that there was an annual survey and they were notified of the outcome and progress in making improvements. A ‘Bright Idea’s’ scheme enabled staff to make suggestions that would improve the NHS Blood and Transplant’s efficiency and effectiveness.

An annual cycle of audits was completed to ensure that the blood donation services remained safe for the staff to work within and met the donor’s needs. The audits covered both the blood centre and the mobile donation sessions. The quality management team monitored any adverse events, accidents and incidents and classed each into one of three key categories (critical – actual harm, major – potential for harm and other – contradiction to policy and procedure).

The quality management audit system also looked at the control of documents and management of equipment. Alerts were sent 30 days before any equipment was due for servicing and maintenance inspections were completed on a six monthly basis, for the equipment that required this level of servicing. Service level agreements were in place for all equipment in the case of mechanical breakdown.

Change control measures were always put in place when introducing any significant changes. An example given was when a new type of single-use lancet for the finger prick test was introduced. There was a programme of staff training, a roll-out of use and an evaluation of the product.

NHS Blood and Transplant was also audited by other regulators for compliance against the Blood Safety and Quality Regulations 2005, the Human Tissue Authority (HTA) and the Medicines and Healthcare Products Regulatory Agency (MHRA). The MHRA completed their last audit in July 2013 and visited the donor centre and one of the donor sessions. Four ‘other’ (contradiction to policy and procedure) areas of non compliance were identified and the quality team were able to report what corrective actions had been taken.

Audits were completed in respect of infection control, venue assessments for the mobile blood donation sessions and completion of documentation, to name some examples. Where shortfalls were highlighted, corrective and preventative action plans were put in place and audits were repeated.

Monthly clinical governance meetings were held and attended by the centre manager or a qualified nurse and the area donor sessions manager. Information was shared between other centres and there were discussions around work load planning, training, quality and any clinical events.

There were stric