Latest Snippet(s)
Positive
"Privacy and dignity The service respected and promoted patients’ privacy and dignity."
2019-04-09 Snippet(s)
Positive
"• Patients privacy and dignity needs at reception were not fully met due to the layout of the reception desk."
Positive
"In the interim the service had put up notices asking for patients waiting to step back from the reception desk to give other patients privacy and dignity."
Latest Snippet(s)
Positive
"Track record on safety The service had a good safety record."
Positive
"The service learned and shared lessons identified themes and took action to improve safety in the service."
Positive
"• All staff received uptodate safeguarding and safety training appropriate to their role."
Positive
"Fire drills and real time evacuations had been completed regularly; we were told the service worked closely with the staff from the adjacent shopping centre in relation to fire safety and security."
Positive
"• There was a strong emphasis on the safety and wellbeing of all staff."
Positive
"• The service learned from external safety events and patient safety alerts."
Positive
"• Leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."
Positive
"Our key findings were : • The service had introduced and maintained comprehensive systems to manage risk so that safety incidents were less likely to happen."
Positive
"• The provider conducted safety risk assessments."
Positive
"Staff received safety information from the provider as part of their induction and refresher training."
Positive
"• There was a system for the management of safety alerts."
Positive
"• There were comprehensive risk assessments in relation to safety issues."
Positive
"• There was a system for receiving and acting on safety alerts."
Positive
"This covered such topics as health and safety information governance and local 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."
Neutral
"Managers had oversight of safety alerts."
2019-04-09 Snippet(s)
Positive
"• The service relied on peer review to assess quality and safety of care and treatment."
Positive
"This was the services first inspection since registration with CQC which found that the service was not meeting some standards of quality and safety it was inspected against."
Positive
"• The service had a fire alarm and safety management plan."
Positive
"Mandatory training • Staff did not receive effective training in all safety systems processes and practices."
Positive
"• The service did not maintain an accurate and complete list of risks relating to the health and safety of service users."
Positive
"Mitigation for this was in place including a fire safety plan and maintenance checks."
Positive
"Incidents • The service managed patient safety incidents well."
Latest Snippet(s)
Neutral
"• Staff had received training in data protection confidentiality and information governance."
Latest Snippet(s)
Positive
"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."
2019-04-09 Snippet(s)
Positive
"We saw an incident was reported for each occasion and actions were taken appropriately for the breach of contract • There was an infection control champion who could be contacted for help and support."
Positive
"Cleanliness infection control and hygiene • We saw all clinical and office areas were visibly clean and tidy."
2019-04-09 Snippet(s)
Neutral
"• Staff told us they would advise patients to make an appointment with their GP for dietitian referral where there were concerns relating to diet and malnutrition."
Latest Snippet(s)
Positive
"Kindness respect and compassion Staff treated patients with kindness respect and compassion."
Positive
"• Staff involved and treated people with compassion kindness dignity and respect."
Positive
"Privacy and dignity The service respected and promoted patients’ privacy and dignity."
Positive
"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."
Positive
"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control."
2019-04-09 Snippet(s)
Positive
"However • Staff treated patients with compassion and respect."
Positive
"• Staff treated patients and relatives with compassion and respect."
Positive
"Emotional support • Staff provided emotional support to patients to minimise their distress."
Positive
"• Patients privacy and dignity needs at reception were not fully met due to the layout of the reception desk."
Neutral
"• Staff provided emotional support to patients when needed to minimise their distress."
Latest Snippet(s)
Positive
"Staff had received equality and diversity training • Openness honesty and transparency were demonstrated when responding to incidents and complaints."
Positive
"• The service actively promoted equality and diversity."
Neutral
"All staff had received training in equality and diversity."
Latest Snippet(s)
Positive
"• The complaint policy and procedures were in line with recognised guidance."
Positive
"One complaint related to a member of staff whose behaviour and conduct was unsatisfactory a full investigation was completed the staff member was subject to an action plan and additional training."
Positive
"• Information about how to make a complaint or raise concerns was available and it was easy to do."
2019-04-09 Snippet(s)
Positive
"Learning from complaints and concerns • The service provided information leaflets for patients about their rights responsibilities and how to make a complaint or express a concern."
Latest Snippet(s)
Positive
"• Structures processes and systems to support good governance and management were clearly set out understood and effective."
Positive
"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management."
Positive
"The governance and management of partnerships joint working arrangements and shared services promoted interactive and coordinated personcentred care."
Positive
"There was a clear and comprehensive threeyear strategic plan which was discussed regularly at governance and strategy meetings."
Positive
"At this inspection we were assured that new systems and process had been introduced and embedded to reduce and mitigate risk audit was well structured and meaningful governance arrangements were comprehensive and well embedded."
Positive
"Significant events and incidents were discussed at management meetings and where necessary at clinical governance meetings locally and regionally."
Positive
"This covered such topics as health and safety information governance and local procedures."
Neutral
"• Staff were trained in information governance and the service was registered with the information commissioner’s office ICO."
2019-04-09 Snippet(s)
Positive
"Governance • At location level we were not assured there were adequate governance systems in place to identify areas of concern and continually improve the service."
Positive
"This risk had not been identified by the service’s internal governance structure."
Positive
"• The service governance structure and committees fed into Virgin care corporation."
Positive
"We had concerns in relation to the governance oversight of the service and the monitoring systems and processes in place."
Positive
"Therefore we were still not assured that there were adequate governance systems in place."
Neutral
"Following inspection we were provided with information at provider level for governance systems and processes."
Neutral
"The service had a governance dashboard for the location which was reported monthly to the governance committee."
Latest Snippet(s)
Positive
"• There was a common focus on improving the quality and sustainability of care."
Positive
"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."
Latest Snippet(s)
Positive
"Monitoring care and treatment The service had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."
Positive
"• The service was actively involved in quality improvement activity."
Latest Snippet(s)
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."
2019-04-09 Snippet(s)
Positive
"This report describes our judgement of the quality of care at this location."
2019-04-09 Snippet(s)
Positive
"The door was clearly labelled with appropriate signage and access instruction."
Positive
"• The service had an exclusion list and sign posted patients to the most appropriate service as needed."
Neutral
"The signage displayed outside contained the name of the previous provider at the time on inspection."
Neutral
"The registered manager told us the signage would be changed after the lease had been signed."