What is the Quality of Safety at St Mary's Urgent Treatment Centre

Positive

"• There was a programme of quality improvement including clinical audit which had a positive impact on quality of care and outcomes for patients."

Positive

"Clinical audit had a positive impact on quality of care and outcomes for patients."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"This recognises the significant improvements made to the quality of care provided by the service."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"Privacy and dignity The service respected and promoted patients’ privacy and dignity."

Positive

"• Curtains were provided in consulting room to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"Privacy and dignity The service respected and promoted patients’ privacy and dignity."

Positive

"• Curtains were provided in consulting room to maintain patients’ privacy and dignity during examinations investigations and treatments."

Neutral

"• Review auditory privacy at all points of patient access to the service."

Positive

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"The service learned and shared lessons identified themes and took action to improve safety in the service."

Positive

"• The provider had identified the three most common languages requested at the service and produced leaflets aligned to those languages and had installed information screens in the waiting room displaying information about chaperoning safeguarding how to make a complaint and fire safety in English and the identified languages."

Positive

"• There was an open and transparent approach to safety and systems were in place for recording reporting and sharing learning from significant events."

Positive

"• Staff told us they received safety information from the service as part of their induction and ongoing training which included health and safety and moving and handling."

Positive

"• Leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"Leaders had oversight of patient safety alerts incidents and complaints."

Positive

"Track record on safety • The service had acted upon findings of previous inspections and were able to demonstrate improvements for example the xray monitoring process for missed fractures."

Positive

"• There were risk assessments in place relation to safety issues for example premises and equipment."

Positive

"The provider had an induction programme for all newly appointed staff which included health and safety role specific training and policies and procedures."

Positive

"• The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service."

Neutral

"This helped it to understand risks and gave a clear accurate and current picture that led to safety improvements."

Positive

"Track record on safety At our previous inspection the service had not been able to demonstrate a good safety record and we had found concerns which impacted on patient safety."

Positive

"– Requires Improvement At this inspection we found: • The provider had addressed the findings of our previous inspection and was able to demonstrate improvements in safeguarding staffing fire safety and systems and process for the sharing of learning and outcomes from significant events and patient safety alerts."

Positive

"In addition an information screen had been installed in the waiting room and was displaying information on chaperoning safeguarding how to make a complaint and provide feedback and fire safety in English and the identified languages."

Positive

"We saw minutes of clinical operational and quality and safety meetings."

Positive

"• There was a strong emphasis on the safety and wellbeing of all staff."

Positive

"• There was an open and transparent approach to safety and systems were in place for recording and reporting significant events."

Positive

"Staff told us they received safety information from the service as part of their induction and ongoing training which included health and safety and manual handling."

Positive

"• We looked at and discussed two recent serious incidents in detail and saw there were adequate systems for reviewing and investigating when things went wrong and saw that lessons had been learned and action taken to improve the safety in the service."

Positive

"• Leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"• Systems had been introduced to manage patient safety alerts and staff were able to give examples."

Positive

"At this inspection the provider demonstrated improvements had been made and we found: • Comprehensive risk assessments had been undertaken in relation to safety issues."

Positive

"• There were mechanisms in place to receive and act on patient safety alerts."

Positive

"We saw the provider had reiterated staff safety and how to raise an alarm in the monthly bulletin."

Positive

"We saw that there was ownership of the risk register and it was reviewed and updated at fortnightly quality and safety meetings attended by the service leads."

Positive

"• The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service."

Neutral

"We saw evidence that the provider had addressed staff safety and its approach to zero tolerance following some incidents of abusive behaviour by patients."

Positive

"• An effective system and process to ensure learning and outcomes from incidents and patient safety alerts were effectively shared with all staff."

Positive

"The provider had recently revised the format of its staff bulletin to include incidents complaints compliments and patient safety alerts to enable better communication to staff."

Positive

"Medicines Management On the day of the inspection we found the arrangements for managing medicines including emergency medicines and vaccines in the service minimised risks to patient safety including obtaining prescribing recording handling storing security and disposal."

Positive

"• There was no formal process in place to ensure patient safety alerts were shared with all staff."

Positive

"• The provider could not demonstrate that all staff had undertaken identified training in line with its policy which included safeguarding children safeguarding adults fire safety awareness infection prevention and control and basic life support."

Positive

"Overview of safety systems and processes Systems and processes in place to minimise risks to patient safety were not clearly defined and embedded."

Positive

"• The provider had identified a range of training for all staff which included safeguarding children and adults basic life support fire safety awareness infection prevention and control equality and diversity and information governance."

Positive

"This indicated there were gaps in training for clinical staff in safeguarding basic life support fire safety awareness infection prevention and control equality and diversity and information governance."

Positive

"• Staff had received training which included safeguarding children safeguarding adults fire safety awareness infection prevention and control and basic life support in adherence to the provider policy."

Positive

"• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns."

Positive

"• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns."

Positive

"The provider told us that the trust estate was due to upgrade external signage as part of the UTC way finding pilot."

Neutral

"At the time of our inspection updated PGDs were with the Clinical Commissioning Group CCG for sign off."

Positive

"However we did observe that the hospital trust estate had Arabic signage in place outside A&E."

Positive

"Kindness respect and compassion During our inspection we observed that members of staff were courteous and helpful to patients and treated them with kindness respect and compassion."

Positive

"Positive comments included good service reassuring caring and patients felt they were treated with dignity and respect."

Positive

"• Staff involved and treated people with compassion kindness dignity and respect."

Positive

"However we found some areas of noncompliance in respect of good governance and the provider was rated requires improvement overall."

Positive

"Privacy and dignity The service respected and promoted patients’ privacy and dignity."

Positive

"• Staff we spoke with were clear about their roles and accountabilities and responsibilities in respect of safeguarding incident reporting and infection prevention and control."

Positive

"In addition we took enforcement action in the form of a warning notice in respect of good governance."

Positive

"• Curtains were provided in consulting room to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"Kindness respect and compassion During our inspection we observed that members of staff were courteous and helpful to patients and treated them with kindness respect and compassion."

Positive

"• Staff involved and treated people with compassion kindness dignity and respect."

Positive

"Comments included very good and quick service and that they were treated with dignity and respect."

Positive

"Privacy and dignity The service respected and promoted patients’ privacy and dignity."

Positive

"• Staff recognised the importance of people’s dignity and respect."

Positive

"Feedback from CQC comments cards was that patients felt they were treated with dignity and respect."

Positive

"• Staff were clear on their roles and accountabilities including in respect of incident reporting safeguarding and infection prevention and control."

Positive

"• Curtains were provided in consulting room to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"• On the day of the inspection we observed members of staff were courteous and helpful to patients and treated them with dignity and respect."

Positive

"Comments included that it was a great service with a high level of professionalism and staff treated them with dignity and respect."

Positive

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"• We saw equality and diversity training formed part of the provider’s mandatory training schedule and we saw evidence that this had been undertaken by clinical and nonclinical staff."

Positive

"• The service actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"• The service actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"• The provider had identified a range of training for all staff which included safeguarding children and adults basic life support fire safety awareness infection prevention and control equality and diversity and information governance."

Positive

"This indicated there were gaps in training for clinical staff in safeguarding basic life support fire safety awareness infection prevention and control equality and diversity and information governance."

Positive

"• The service analysed complaint trends as we saw that they had identified clinical treatment staff attitude and behaviours and appointments including delays as the three main complaints."

Positive

"• The provider had identified the three most common languages requested at the service and produced leaflets aligned to those languages and had installed information screens in the waiting room displaying information about chaperoning safeguarding how to make a complaint and fire safety in English and the identified languages."

Positive

"• Patient information about how to make a complaint or raise concerns was available in English and other languages which the provider had identified as the common languages requested at the service."

Positive

"The provider was aware that some complaint targets were not being met and additional governance at a regional level had been implemented to establish consistency and work towards compliance."

Positive

"The complaint policy and procedures were in line with recognised guidance and was accessible to staff."

Positive

"In addition an information screen had been installed in the waiting room and was displaying information on chaperoning safeguarding how to make a complaint and provide feedback and fire safety in English and the identified languages."

Positive

"• Patient information about how to make a complaint or raise concerns was available in the centre in English Polish Spanish and the Arabic language."

Positive

"• The provider’s website included the complaint policy and how to feedback complaints and concerns by telephone email and post."

Positive

"From those we reviewed we saw that patients had received a written response with details of the Ombudsman’s office provided in case the complaint was not managed to the satisfaction of the patient."

Positive

"• Structures processes and systems to support good governance and management were clearly set out understood and effective."

Positive

"However we found some areas of noncompliance in respect of good governance and the provider was rated requires improvement overall."

Positive

"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management at local and regional level."

Positive

"The provider was aware that some complaint targets were not being met and additional governance at a regional level had been implemented to establish consistency and work towards compliance."

Positive

"There was oversight from the regional governance team of incidents and complaints at the centre to improve response times."

Neutral

"• Continue to review and monitor the governance oversight of the complaints response process to ensure these are managed within the appropriate timeframes."

Neutral

"At this inspection we saw that a regional level of oversight had been implemented through a serious case initial findings SCIF process facilitated by the regional governance team to ensure information gathering and coordination took place in a timely manner."

Neutral

"• We met with the regional governance coordinator who told us where the response timeframe had not been met the complainant received an update on the progress of the complaint."

Neutral

"• There was an overarching regional and national governance structure."

Positive

"• Structures processes and systems to support good governance and management were clearly set out understood and effective."

Positive

"The areas where the provider must make improvements as they are in breach of regulations are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"At this inspection we found that the provider had implemented clear responsibilities roles and systems of accountability to support good governance and management at both local and organisational level."

Positive

"Governance arrangements At our previous inspection we found the provider had not implemented a governance framework at a local or an organisational level to ensure the delivery of good quality care and opportunities to prevent or minimise harm had been missed."

Positive

"The provider demonstrated it had engaged with its commissioners and the trust to improve governance and bring about improvements to patient outcomes."

Positive

"The induction included a corporate and local overview safeguarding incident reporting information governance and rolespecific topics such as assessing mental capacity medicine management streaming guidance identifying serious illness and red flags."

Positive

"A governance coordinator had recently been recruited to oversee operational and clinical incidents organisationwide and an interim Are services safe?"

Neutral

"The service attributed this to the level of experience of incident management and investigation within the team and governance staff turnover."

Positive

"• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"• Although the service had an overarching organisational governance framework this had not been implemented adequately at a local or organisational level to ensure the delivery of good quality care and opportunities to prevent or minimise harm were missed."

Positive

"Governance arrangements Although the service had an overarching organisational governance framework this was not implemented adequately at a local or organisational level to ensure the delivery of good quality care and opportunities to prevent or minimise harm were missed."

Neutral

"• There was evidence of some governance including with stakeholders and staff meetings but these had not been regularly held."

Neutral

"• Although we saw minutes of governance and staff meetings which included governance meetings with the hospital trust and commissioners there was no structured meeting schedule in place."

Positive

"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."

Positive

"However it was not possible to measure the stability and sustainability of the improvements made so far over time."

Positive

"• There was a programme of quality improvement including clinical audit which had a positive impact on quality of care and outcomes for patients."

Positive

"The service had a comprehensive programme of quality improvement activity and routinely received the effectiveness and appropriateness of the care provided."

Positive

"The areas where the provider should make improvement are: • Consider the infection control lead undertaking enhanced training to support them in this extended role."

Positive

"Action the service SHOULD take to improve • Consider the infection control lead undertaking enhanced training to support them in this extended role."