Inspection Question Is it Effective? The Report from CQC
The CQC inspector’s rated Effective as Good
- The provider had systems and procedures which ensured clinical care provided was in relation to the needs of service users. Staff at the service had the knowledge and experience to be able to carry out their roles
Effective needs assessment, care and treatment
The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)
- The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
- Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
- Clinicians had enough information to make or confirm a diagnosis
- We saw no evidence of discrimination when making care and treatment decisions.
- Arrangements were in place to deal with repeat patients. If a service user required a follow-up consultation, an appointment suitable with the service user was made by service staff to ensure the continuity of on-going treatment.
- Staff assessed and managed patients’ pain where appropriate.
Monitoring care and treatment
The service was involved in quality improvement activity.
- The service had been registered with the Commission from November 2018 and therefore had conducted a limited number of audits. There was no evidence of a plan of how often quality improvement and clinical audits would be undertaken by the service. We viewed an audit of post operation service users and their experiences following surgery whilst still at the hospital. As a result of the audit, the service has introduced an extended period monitoring service user (including provision of fluids) within the service before allowing them to leave the service. The service made improvements through the use of completed audits. There was clear evidence of action to resolve concerns and improve quality.
Staff had the skills, knowledge and experience to carry out their roles.
- All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
- Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC and were up to date with revalidation
- The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
Coordinating patient care and information sharing
Staff worked together, and worked well with other organisations, to deliver effective care and treatment.
- Patients received coordinated and person-centered care. Staff referred to, and communicated effectively with, other services when appropriate.
- Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
- All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
- The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
- Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other service.
Supporting patients to live healthier lives
Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.
- Where appropriate, staff gave people advice, so they could self-care.
- Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
- Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
Consent to care and treatment
The service obtained consent to care and treatment in line with legislation and guidance
- Staff understood the requirements of legislation and guidance when considering consent and decision making.
- Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
- The service monitored the process for seeking consent appropriately.
The 5 Areas which the CQC investigated.