We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Colchester Alliance MRI Unit Colchester General Hospital, Turner Road, Colchester, CO4 5JL Tel: Date of Inspection: 19 November 2013 Date of Publication: December 2013 We inspected the following standards as part of a routine inspection. This is what we found: Care and welfare of people who use services Cooperating with other providers Requirements relating to workers Complaints Met this standard Met this standard Met this standard Met this standard Inspection Report Colchester Alliance MRI Unit December

2 Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activity Alliance Medical Limited Mrs. Sarah Warner Alliance Medical provides a magnetic resonance imaging (MRI) centre at Colchester General Hospital. The service provides a range of MRI scans for adults and children as part of the hospital care. The centre also provides scans for people who have been referred privately. Diagnostic and/or screening service Diagnostic and screening procedures Inspection Report Colchester Alliance MRI Unit December

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Care and welfare of people who use services 6 Cooperating with other providers 8 Requirements relating to workers 9 Complaints 11 About CQC Inspections 13 How we define our judgements 14 Glossary of terms we use in this report 16 Contact us 18 Inspection Report Colchester Alliance MRI Unit December

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 19 November 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff. What people told us and what we found We spoke with three relatives who accompanied people for their scans. We were unable to speak with people as they were being scanned throughout the duration of our inspection; however we did observe their care. Relatives told us that staff were kind and supportive. One person told us, "The whole process has been really quick, we have no complaints." We saw that people had been provided with information about their scan and that any questions had been answered before they consented to the procedure. We saw that each person went through a safety checklist prior to being scanned which ensured their safety and welfare. The service had a comment and feedback box for people to provide feedback on the service to help them improve. The people we spoke with said they felt listened to and were happy with the service provided. We examined the recruitment procedures for staff employed by the service and found that staff were appropriately skilled and qualified to undertake their roles. The registered manager was not present on the day of our inspection; however the staff we spoke with were clear about procedures and were able to assist us. We spoke with the registered manager after the inspection had been carried out and obtained some additional information. The way in which information was provided during and after the inspection showed that there was good leadership and understanding of roles and functions within the service. You can see our judgements on the front page of this report. Inspection Report Colchester Alliance MRI Unit December

5 More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Colchester Alliance MRI Unit December

6 Our judgements for each standard inspected Care and welfare of people who use services Met this standard People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Reasons for our judgement The service had a two stage approach to people being booked to receive a magnetic resonance imaging (MRI) scan within the service. For outpatients we saw that an assessment for a scan was completed by the referring practitioner. For people who required a scan whilst a patient at Colchester General Hospital referrals were made by the hospital staff. We saw that these were sent to the MRI centre and then reviewed by the Consultant radiologist who ensured it was appropriate for the patient to receive an MRI scan. When approved all referrals were triaged in order of urgency and priority to be seen. Prior to arrival people received information which was relevant to their scan, this included specific information for example, for children and people that had any metal inside their body. We saw that upon arrival outpatients were asked to complete a safety questionnaire. For inpatients who had been booked for a scan the safety checklist was completed by the person on the ward prior to being taken for a scan. Prior to the scan this safety checklist was further discussed with the patient before the scan was carried out which ensured that the person was safe to be scanned. We observed one person who spoke with staff prior to the scan being carried out and saw that staff asked encouraged people to ask any questions they had. We observed that staff carried this out in a manner that reassured and supported the person. This meant that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We examined the referral and safety checklists for eight people who used the service. Six were for nonhospital people and two were for hospital inpatients. We found that the checklists had been completed and signed by the person who received the scan. We saw in one case a person did not have mental capacity to complete their safety checklist form; in this case a different form was completed by the referring doctor with decisions made in the best interest of the person. We spoke with a radiographer and a staff member about cases where a person does not have capacity to consent. They told us they reviewed the information submitted and when the person arrived in the department and then a further capacity assessment was completed prior to the scan being carried out. We were told this Inspection Report Colchester Alliance MRI Unit December

7 ensured the safety or welfare of the person who required the scan was protected. This meant that interests of the person had been considered and assessed appropriately. We found that some information on the referral forms was not always legible. We spoke with a staff member and two radiographers who told us that where the instructions were unclear, they rejected the requests or requested further guidance. They told us that they would not scan people unless they were clear what was required. This meant that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We found that the service had access to interpreter and advocate services. We saw that the provider could access both the internal hospital interpreter and advocate services for hospital patients but that the service also had their own interpreter service available through Alliance Medical. The need for an interpreter or advocate is assessed at the time of referral to the MRI unit. The arrangements are made once the referral is accepted and processed. This meant that people's needs were assessed and care and treatment was planned and delivered in line with their individual care needs. We saw that the provider had systems in place to deal with emergencies such as sudden illness as they were based within Colchester General Hospital and could call for medical assistance if it was required. We also found that staff within the unit had received basic life support and advanced life support training dependent on their role and all staff could therefore participate in an emergency event if required. We spoke with staff who informed us of recent changes to MRI scanning for people with pacemakers. We were informed that some pacemakers were no compatible with MRI scanners. The staff informed us that they had recently scanned a person with a pacemaker and that this procedure had been risk assessed. We were told that to ensure the safety of the person they had the resuscitation and cardiology teams on standby in the unit whilst the scan was conducted should an emergent situation occur. This meant that there were arrangements in place to deal with foreseeable emergencies. Inspection Report Colchester Alliance MRI Unit December

8 Cooperating with other providers Met this standard People should get safe and coordinated care when they move between different services Our judgement The provider was meeting this standard. People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. Reasons for our judgement The service used a formal process for referring care to other providers when appropriate, for example when someone required the use of bariatric facilities to meet their needs. We viewed examples where an MRI referral had been received but the person required bariatric facilities, or where they had metal in their body to complete their scan safely. We saw that there was a flow chart and procedure used within the service which detailed where referrals were sent and at what stage. This demonstrated that the service had assessed people's needs in advanced which ensured that appropriate service links were established to treat all people where possible and meet their individual needs. The MRI Unit was based within Colchester General Hospital and provided a service to hospital patients as well as people who were treated privately. We asked the manager and the staff how the service cooperated with the Trust to ensure that all people received safe and effective care. The manager informed us that they worked alongside the trust radiology department and attended the monthly Radiology Clinical Governance meetings. They also informed us that Alliance Medical also had regular monthly service review meetings with the radiology manager which ensured the continuity with the service. This meant that the provider worked in co-operation with others to ensure the safety and welfare of people who used the service. Inspection Report Colchester Alliance MRI Unit December

9 Requirements relating to workers Met this standard People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by, suitably qualified, skilled and experienced staff. Reasons for our judgement We found there were effective recruitment and selection processes in place. The registered manager provided us with information and procedures relevant to the recruitment of staff within Alliance Medical. We looked at staff records as part of the inspection, this included evidence of health and care professional council (HPC) registration before employment commenced. All staff were required to submit a copy of their certificate upon renewal to the registered manager and the HR department. This information was reviewed by the registered manager which ensured compliance with people's professional registrations. This meant that appropriate checks were undertaken before and after staff began work. We spoke with three radiographers and three support staff. All were knowledgeable about their role and provided clear examples of what their roles were. For example we asked staff about the risks and safety checks required of MRI scanning and we were provided with clear and detailed answers that confirmed staff had the appropriate knowledge to undertake their role in a safe and effective manner. We spoke with three relatives about the staff during our inspection. All three told us that the staff were kind and appeared knowledgeable. One person told us, "They know what they are doing, they have always answered mine and my (relatives) questions. " This meant that people felt that they and their relatives were cared for, or supported by skilled and experienced staff. We asked the registered manager if any staff had been referred to their professional body as a result of misconduct since our last inspection. We were told by the manager that no staff member had been referred to their professional bodies in the previous twelve months. We were provided with the policy for referring people to the relevant professional body which demonstrated that there was a clear procedure in place if required. This meant that if staff who were no longer fit to work in health or social care they would be referred to the appropriate bodies. The registered manager showed us the provider had a policy in place for the recruitment of staff. The policy contained effective processes which ensured people were not discriminated against during recruitment. Appropriate checks were undertaken before staff began work. We saw evidence staff employed by the provider had been through recruitment checks prior to commencing employment. Identity checks had been completed Inspection Report Colchester Alliance MRI Unit December

10 and other checks included a police clearance check, employment and character references and any professional registrations held. This meant that there were effective recruitment and selection processes in place. Inspection Report Colchester Alliance MRI Unit December

11 Complaints Met this standard People should have their complaints listened to and acted on properly Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately Reasons for our judgement The MRI unit had two processes for the handling and management of complaints. If the person who wished to make a complaint was a patient of Colchester General Hospital the person would be referred to the hospital patient advice and liaison service (PALS.) If the person was referred to the service from outside the hospital, for example through a private referral, they would be directed to the Alliance Medical complaints procedure. This meant that there was an effective system in place that ensured people who used the service were provided with the appropriate information to make a complaint or compliment about the service. Leaflets about how to make a complaint were readily available in the reception area of the unit. Information about the patient advice and liaison service (PALS) were also available if people required their assistance to make a complaint or suggestion. The complaints procedure contained specific targets and guidelines for dealing with and responding to complaints. This meant that staff had access to guidance which helped them to make an appropriate response to complaints received. We found that the complaints procedure was available in Braille and large print versions. We also found there was a language line available in case there were any concerns raised by patients whose first language was not English. This demonstrated that people were made aware of the complaints system. This meant that the people were given support by the provider to make a comment or complaint where they needed assistance. This was also provided in a format that met their needs. We received a summary of complaints people had made and the provider's response. The manager told us all complaints were reported to head office and they monitored the outcomes of the investigations. We found that four complaints had been made about the service provided by alliance Medical since our last inspection. The manager provided us with a summary of these complaints, the actions taken and the responses sent in two cases. We saw that in each case the Alliance Medical complaints policy had been followed and that people's complaints were fully investigated and resolved, where possible, to their satisfaction. For complaints made that related primarily to the care of a hospital patient the manager told us that these complaints are reported through the Hospital reporting system. Any complaints that are received by PALS are investigated by the most appropriate trust Inspection Report Colchester Alliance MRI Unit December

12 manager. If any part of these complaints relates to MRI then the manager would be requested by the investigating officer to provide a response to the investigation with their findings. The investigating officer would then prepare a full response letter. This meant where different services were involved in delivering care or treatment the provider took appropriate action to co-ordinate a response to the person raising the complaint. Inspection Report Colchester Alliance MRI Unit December

13 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Colchester Alliance MRI Unit December

14 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Colchester Alliance MRI Unit December

15 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Colchester Alliance MRI Unit December

16 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Colchester Alliance MRI Unit December

17 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Colchester Alliance MRI Unit December

18 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Colchester Alliance MRI Unit December