Is it Safe?

Inspection Question Is it safe? The Report from CQC

The CQC inspector’s rated safe as Good


  • The provider had systems and procedures which ensured that users of the service and information relating to service users were kept safe. Medicines at the service were kept securely and regularly monitored to ensure that they were fit-for-purpose. A health and safety evaluation of the service had been completed by an external contractor. All actions identified as a result of the evaluation had been actioned by the provider. 

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had some systems in place to assure that an adult accompanying a child had parental authority. This was usually through verification of the patient via their parent’s health insurance. The service had a low number of patients under the age of 18.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • The service had employed an external company to conduct a Health and Safety evaluation of the service. This evaluation was completed in October 2018. Whilst the overall summary of the evaluation was that the service’s health and safety management was satisfactory, there were some actions necessary to improve safety management at the site. We noted that there were no completion dates on the action plan provided to the service to comply with the areas identified by the external contractor as requiring action within an agreed timescale. Subsequent to the inspection, we received evidence in the form of completion certificates and invoices for work completed, that outstanding actions identified had been completed.
  • There was an effective system to manage infection prevention and control. The service conducted weekly infection control audits. Any issues regarding infection control were taken forward by the hospital co-ordinator to resolve the issue. The service’s building had undergone a legionella risk assessment in July 2018 and weekly monitoring of water temperatures was conducted by the service.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. We saw evidence of the latest fire assessment which was conducted in June 2018.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When reporting on medical emergencies, the guidance for emergency equipment is in the Resuscitation Council UK guidelines and the guidance on emergency medicines is in the British National Formulary (BNF).
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service employed a pharmacist who ensure that medicines kept on site were done so in accordance with legislation and manufacturers guidance. The service kept prescription stationery securely and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that would lead to safety improvements.

Lessons learned, and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and took action to improve safety in the service. The service spoke to us about an incident where a service user leaving the building during winter tripped on the outside step. Service staff based on reception went to assist the service user was not hurt. As a result of this incident, additional lighting was placed outside the building to highlight the step and if a member of staff saw older service user approaching the building they would go outside and assist the service user into the building.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service told us that it acted on and learned from external safety events as well as patient and medicine safety alerts. However, the service did not have in place a process for receiving and disseminating safety alerts to relevant personnel within the service. We asked how the service assured itself that care was being provided in line with current safety alerts advice and was told that several clinical staff were able to access the alerts through external sources.

View details from CQC Page

The 5 Areas which the CQC investigated.

Download CQC inspection report PDF

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