Review of compliance. Craigweil Dental Practice Craigweil Dental Practice. South East. Region: Grand Avenue Lancing West Sussex BN15 9PS

Transcription

1 Review of compliance Craigweil Dental Practice Craigweil Dental Practice Region: Location address: Type of service: South East Grand Avenue Lancing West Sussex BN15 9PS Dental service Date of Publication: July 2012 Overview of the service: Craigweil Dental Practice is a family dental practice in Lancing, West Sussex. Principal Dentist Dr. Mehrdad Seifouri provides a range of general, preventative, restorative, and cosmetic treatments for patients of all ages. The practice also has a dental hygienist who specialises in prevention of common dental problems. The practice provides dental care under the National Health Service (NHS). Page 1 of 26

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement Craigweil Dental Practice was not meeting one or more essential standards. Action is needed. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 14 June 2012, talked to staff, reviewed information from stakeholders and talked to people who use services. What people told us We spoke with a range of people about the service, including the principal dentist, a dental nurse, the practice manager, a receptionist, a representative from the primary care trust (PCT), and five people who use the service. The people using the service told us they were very satisfied with their dental care. People told us that treatment options were discussed with them, including their associated costs and risks. People using the service said the premises and treatment areas were generally clean and their privacy was upheld during treatment. One patient said of the practice, "I've always received very good care" Staff told us that they were happy working for the practice. They told us that the team worked well together. What we found about the standards we reviewed and how well Craigweil Dental Practice was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run People's privacy, dignity and independence were respected. People were given information and support to inform their decisions. The provider was meeting this standard. Page 2 of 26

3 Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights People experienced care, treatment and support that met their needs and protected their rights. The provider was meeting this standard. Outcome 07: People should be protected from abuse and staff should respect their human rights People who use the service were not protected from the risk of harm, because the provider had not taken reasonable steps to identify the possibility of harm and prevent it from happening. Risk assessments, staff training in safeguarding, appropriate background checks, complaints and concerns documentation, and clear policies were not in place to ensure patients were protected from risk of harm or abuse. Outcome 08: People should be cared for in a clean environment and protected from the risk of infection People were not protected from the risk of infection because appropriate guidance and procedures had not be implemented and followed. The practice had some policies and procedures in place around infection control and decontamination, but these policies were not being followed consistently. Current practices by staff present a risk to the spread of infection. In addition, the practice did not have clear methods of documenting and auditing their practices for quality assurance measures. Staff had not been appropriately trained in infection control, health and safety, and decontamination guidance. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills People were cared for by staff who were not sufficiently supported to deliver care and treatment safely and to an appropriate standard. Staff training and development were not documented in any formal way to ensure staff were sufficiently supported or meeting their own professional goals. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care The provider did not have an effective system to regularly assess and monitor the quality of service that people received. Page 3 of 26

4 Actions we have asked the service to take We have asked the provider to send us a report within 14 days of them receiving this report, setting out the action they will take. We will check to make sure that this action has been taken. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Other information Please see previous reports for more information about previous reviews. Page 4 of 26

5 What we found for each essential standard of quality and safety we reviewed Page 5 of 26

6 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that 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. A moderate impact means that 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. A major impact means that 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. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 6 of 26

7 Outcome 01: Respecting and involving people who use services What the outcome says This is what people who use services should expect. People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered. What we found Our judgement The provider is compliant with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us People we spoke with told us that they were happy with the services provided at Craigweil Dental Practice. They told us that all treatment and consultations had taken place in a manner which protected their privacy. People told us that they had been provided with a treatment plan which explained their treatment options and relevant costs. They told us that alternative options and risks had been discussed with them so they could make an informed decision. One person told us, "I've always received very good care." Another person described how treatment decisions were left to him, "I discuss price. It's up to me whether we go ahead [with treatment]." We spoke with a parent whose child received treatment at the practice. The parent told us that the dentist discussed the treatment plan and requested consent from the parent who was present in the room. This person said that treatment was also explained to the child as best as possible to inform and comfort the young patient. Other evidence People who use the service understood the care and treatment choices available to them. People who use the service were given appropriate information and support regarding their care or treatment. Page 7 of 26

8 Craigweil Dental Practice had a website that provided people with information about the practice. The website included the practice's mission statement, information about the treatments available, explanation of treatments, guidance for good oral care, practice contact information, and external resources. We found the practice had secure storage systems for patient records. In addition to being stored in the password-protected computer system, paper records were kept in locked cabinets. We found that the practice had a policy in place addressing consent and patient rights. The policy stated that patients had the right to refuse consent or change their minds about treatment. The dentist and staff told us that consent was primarily given verbally. If a patient had a more complicated treatment plan, signed consent may also be requested. The consent policy stated, "we should make a note in patient notes." We viewed eight patient records which were stored on a computer database called Exact Dental. The treatment plans documented patient involvement and consent in treatment planning by using phrases such as: "informed consent given," "patient happy with treatment," "advice given," and "patient does not want." However, the provider may find it useful to note that documentation of consent was inconsistent for patients under the age of 16. The records for children did not indicate who the representative was and how consent was given. This was discussed with the principal dentist at the conclusion of our inspection. The practice had a "suggestion box" near the front door of the practice to encourage patients to give anonymous feedback. The practice manager told us the team plans to survey patient satisfaction formally in the coming months. Our judgement People's privacy, dignity and independence were respected. People were given information and support to inform their decisions. The provider was meeting this standard. Page 8 of 26

9 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found Our judgement The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us The people we spoke with said they were happy with the treatment they had been provided by the practice. One person described the practice as "very good." Another person commented, "I'm satisfied." Another patient told us they found their experience to be "informative." People said they were involved in their treatment plans and the options, costs, and risks associated with treatment were discussed with them. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Other evidence Care and treatment was planned and delivered in a way that ensured people's safety and welfare. The practice was arranged on one floor which made it accessible for people with physical impairments. The principal dentist also told us they had a portable ramp that was used to assist people with wheelchairs. We found that the practice had a policy in place addressing consent and patient rights. The policy stated that patients had the right to refuse consent or change their minds about treatment. We viewed a sample of eight patient records. Each record contained a relevant medical and dental history. The treatment notes indicated that the accuracy of medical Page 9 of 26

10 history was checked at the patient's most recent visit. Each patient file we viewed had treatment notes that documented the discussions and treatment provided. The treatment notes included phrases such as "medical history checked," "oral hygiene instructions reinforced," "advice given," and "patient happy with treatment." The practice had first aid, emergency drug, and mercury spillage kits available in the event of emergencies of that nature. However, the provider may find it useful to note that the sterile dressings in the first aid kit were out of date. Also, the emergency drug kit included controlled drugs which should be secured in a locked receptacle. This was discussed with the provider at the conclusion of our inspection. Care and treatment was planned and delivered in a way that ensured people's safety and welfare. Our judgement People experienced care, treatment and support that met their needs and protected their rights. The provider was meeting this standard. Page 10 of 26

11 Outcome 07: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found Our judgement The provider is non-compliant with Outcome 07: Safeguarding people who use services from abuse. We have judged that this has a minor impact on people who use the service. Our findings What people who use the service experienced and told us The people we spoke with said they felt safe when receiving treatment. They had never had to raise a complaint or concern with the practice, but would feel comfortable to do so. Other evidence People who use the service were not protected from the risk of harm because the provider had not taken reasonable steps to identify the possibility of harm and prevent it from happening. Staff told us they had not received training from the practice in safeguarding vulnerable adults and children, despite the fact that a significant number of their patients were children or older adults. Staff had not had training in the Mental Capacity Act or Deprivation of Liberties Safeguards. When asked, staff were unable to tell us how the practice would handle a safeguarding concern. Staff were vaguely aware there was written guidance somewhere in the practice office, but were unable to locate it during our visit. Staff told us they had received some safeguarding information in their previous work, educational, or volunteer experiences, but this was completed more two years ago and was not specifically related to safeguarding in the dental sector. Craigweil Dental Practice had a policy related to child protection and safeguarding vulnerable adults, which included information about types and signs of abuse as well as a flow chart for reporting. However, in speaking with staff, it was evident that this Page 11 of 26

12 information was not clearly disseminated and staff had not had appropriate training in these procedures. The staff we spoke with were able to verbalise their understanding of reporting procedures when questioned. One person responded that she would discuss any concerns with the dentist, but after that, "I don't know where you'd go from there." Staff told us they had not yet received cardio pulmonary resuscitation (CPR) and basic first aid training, but we were told this training was booked for all staff for July At the time of our visit, the only person with a valid Criminal Records Bureau (CRB) check was the principal dentist. One staff person's CRB was in process. All other staff had CRB's from previous work and volunteer roles outside the dental sector that were at least two years old. We discussed with the principal dentist that a reliable CRB should include the practice name and the individual's job title within the organisation for which they current work. At the time of our visit, the only risk assessments in place related to fire safety and the emergency drugs and oxygen supply. We found no evidence of risk assessments that addressed individual patient needs, other environmental risks including tripping/slipping hazards and infection control. We found no evidence of guidance for staff on how these risks can be reduced by staff. Staff had not received training in risk management. The practice was unable to produce an updated complaints and concerns log. The principal dentist said that complaints were primarily handled verbally and informally. The dentist told us that complaints were not generally documented in a log unless the complaint came to them in writing. The practice's complaints policy stated that complaints or concerns raised "should be recorded," but it did not appear that the practice was following this guideline. Craigweil Dental Practice did not have a clear policy about immunization of staff and background checks to ensure patients were protected during treatment. This was supported by speaking with staff, viewing employment records, and viewing the practice policies. Our judgement People who use the service were not protected from the risk of harm, because the provider had not taken reasonable steps to identify the possibility of harm and prevent it from happening. Risk assessments, staff training in safeguarding, appropriate background checks, complaints and concerns documentation, and clear policies were not in place to ensure patients were protected from risk of harm or abuse. Page 12 of 26

13 Outcome 08: Cleanliness and infection control What the outcome says Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. What we found Our judgement The provider is non-compliant with Outcome 08: Cleanliness and infection control. We have judged that this has a moderate impact on people who use the service. Our findings What people who use the service experienced and told us People using the service told us that the premises appeared clean and safe. People told us that they felt safe from the risk of infection. Other evidence People were not protected from the risk of infection because appropriate guidance and procedures had not be implemented and followed. We found evidence that regulations and guidance set by the Department of Health's Code of Practice and the Department of Health's "Health Technical Memorandum (HTM 01-05): Decontamination in primary care dental practices" were not understood or being followed by staff in the practice. Due to its size and layout, the practice did not have a separate decontamination room. Therefore, decontamination procedures were carried out in the surgery room or in the dental hygienist's room when she was not there, as this room also had an autoclave. When the hygienist's room was available, the instruments that were ultrasonically cleaned were carried to the room and put into the autoclave. When the room was not available, the tools were cleaned in the dental surgery room. The dental nurse explained the decontamination process, which included cleaning instruments with a brush to remove surface debris, soaking instruments in an ultrasonic cleaner, and putting instruments through the autoclave steriliser. The dirty instruments were manually cleaned in the same sink where they were rinsed which posed a risk of further cross-contamination. The areas labelled "clean" and "dirty" shared the same counter space and were only separated by a small sink where Page 13 of 26

14 the instruments were manually cleaned and rinsed. Therefore, there was a risk that microorganisms could splash onto "clean" work areas during manual cleaning procedures. Although the autoclave was on a separate counter in the surgery, clean instruments were stored on the same side of the room with dirty instruments and within close proximity to the dirty instrument work space. The decontamination process did not have a clear workflow to demonstrate how dirty instruments were kept sufficiently separated from sterilised ones. There was no evidence that the manual cleaning process included the testing of water temperature or disinfection of the cleaning brush (if re-useable). In addition, the dental nurse carrying out decontamination procedures said that although she wore gloves during the procedures, she did not consistently wear an apron and rarely wore eye protection. The practice's decontamination policy stated, "gloves and eye protection must be worn when handling and cleaning instruments," but it did not appear that this policy was being followed or monitored. The practice's decontamination policy stated that staff should "inspect instruments for residual debris." HTM recommends the use of a magnifying tool with a light to ensure accurate checks for surface debris. When asked if staff use a magnifying tool, the dentist replied, "they [the staff] won't wear it." The dental nurse told us she does not use a magnifying tool to check for debris on instruments. We viewed a tray of cleaned mouth mirrors whose surfaces appeared to have residue. We were told that the only instruments that were wrapped after sterilisation were forceps and elevators. This was supported by viewing the practice's policy on decontamination. Instruments that were to be used in the same day were not wrapped and stored in the cabinet. Wrapped items were dated with the date the instruments were sterilised, but not an expiration date. When asked how the staff determine when an instrument's sterilisation had "expired," we were told that they were periodically reviewed. However, this process of review was not clearly outlined, documented, tracked, or audited to ensure quality assurance. The practice kept records of equipment checks and maintenance of decontamination equipment, particularly for the autoclave and replacement of distilled water in this machine. However, there were no records of the decontamination cycles to ensure a system of tracking for quality assurance purposes. Therefore, in the event of an infection outbreak, the practice would be unable to identify where the instrument was used and how it was cleaned. There was no evidence that the practice had carried out audits of their infection control and decontamination procedures to ensure staff were following the protocols. The practice did not have an annual statement of their infection prevention strategy, as outlined by the Department of Health's Code of Practice. The practice did not have a general cleaning policy and procedure in place to prevent cross-contamination of clinical areas and non-clinical areas (such as the restroom or the waiting area). We were told a contracted cleaner comes three day a week, but there was no guidance or documentation which clearly identified how the contracted cleaner would carry out cleaning duties, in which areas, with which supplies, and with Page 14 of 26

15 what frequency. In addition, the cleaner's daily cleaning tasks were not documented or audited for the purposes of quality assurance measures. We were told that the cleaner has not had infection control or health and safety training. We were told by the dentist that the cleaner doesn't always wear gloves or other personal protective equipment (PPE) when carrying out the tasks. The dentist said the cleaner doesn't like to wear an apron because "it cramps her style." Inconsistent use of PPE by the cleaner puts the cleaner at risk of contracting an infection and puts patients at risk of acquiring an infection carried by the cleaner. We were told that the cleaner uses the same mop and sponges/rags for all areas which poses a risk for cross-contamination. The cleaning supplies, including chemicals, rags, and sponges were stored in the same area where staff store their personal belongings, food, and hot drink supplies. Measures were not taken to ensure appropriate cleaning equipment was stored according to area types (clinical vs. non-clinical) and kept appropriately separated. There was no evidence of guidance about what cleaning supplies were to be used in which areas. This storage arrangement puts staff and patients at risk of infection or illness. The practice's infection control policy stated, "clothing worn on the premises should not be worn outside." However, the dental nurse told us she has routinely worn her uniform outside when commuting to and from work and sometimes wears her uniform twice before washing. As microorganisms can be carried on clothing, this practice could lead to transmission of infection to patients from external sources and could transmit infection to members of the public who come into contact with a dental nurse wearing a soiled uniform outside the surgery. Waste was kept outside the building in a locked storage space. Care was taken to ensure domestic waste was kept separated from clinical waste. We were told that an external company collected their clinical waste at regular intervals. However, we found that clinical waste (including sharps containers) was kept in the same shed as paper patient records. If a staff person needed to access a paper copy of a patient record, he/she would come into contact with medical waste which presents an infection risk to staff and patients. We were told that the only staff who had received infection control training was the principal dentist and the dental nurse. Other staff had not had appropriate training in infection control, decontamination procedures, or current legislative guidance including the HTM and The Code of Practice. When asked about training in this area, the receptionist replied "it's not something I need to know." Our judgement People were not protected from the risk of infection because appropriate guidance and procedures had not be implemented and followed. The practice had some policies and procedures in place around infection control and decontamination, but these policies were not being followed consistently. Current practices by staff present a risk to the spread of infection. In addition, the practice did not have clear methods of documenting and auditing their practices for quality assurance measures. Staff had not been appropriately trained in infection control, health and safety, and decontamination guidance. Page 15 of 26

16 Page 16 of 26

17 Outcome 14: Supporting staff What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by competent staff. What we found Our judgement The provider is non-compliant with Outcome 14: Supporting staff. We have judged that this has a minor impact on people who use the service. Our findings What people who use the service experienced and told us The people we spoke with said they were happy with the treatment they had been provided by the practice. People told us they found staff to be helpful, knowledgeable, and professional. Other evidence Staff had not received appropriate training and professional development. We found that staff received an informal induction to the practice and its daily functions. However, the staff we spoke with had not had recent training in health and safety guidance, infection control, safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards (MCA/DOLs), first aid, and basic life support (CPR). However, we were told that all staff were booked for CPR and first aid training for July Staff could not demonstrate they had been trained in the practice's own policies, as procedures were not being followed accordingly in practice. For example, the complaints policy stated that any issues "should be recorded," but we were told that complaints and concerns were only recorded when the complaint was given in writing. The lead for decontamination and infection control procedures was the principal dentist and he was responsible for training all staff in these protocols. The dental nurse confirmed she had been trained, but no other staff had received any training in this area. The dentist and dental nurses working for the practice were responsible for their own Page 17 of 26

18 continuing professional development (CPD) with the General Dental Council (GDC). We saw evidence that these staff members engaged in independent training exercises to meet these requirements. However, the practice had not provided formal training internally in the areas outlined above. The practice manager was new to the practice and still in her probationary period. The practice manager was eager to learn and develop into her new role, but said there was "room for improvement" as she would like more training in dental practice management. Staff told us that supervision is given on an informal basis as and when issues arise. None of the staff we spoke with had had an annual appraisal or probationary appraisal. There was no evidence that these informal supervision sessions were documented for future reference. Staff told us that they had not held team meetings for some time, but started to organise them again in May, around the time of the new practice manager starting. We viewed the minutes from a recent staff meeting. We were told that staff planned to hold staff meetings on a monthly basis. One staff person told us that she had recently returned to work after a lengthy illness. She told us she had received good support from her colleagues in transitioning back to work. However, she said she had not received any formal refresher training or formal supervision to document her transition and what support she might need given her lengthy absence and underlying health issues. Staff told us that due to their small size, the team works well together and communicates regularly. One person said, "we are quite close knit." Our judgement People were cared for by staff who were not sufficiently supported to deliver care and treatment safely and to an appropriate standard. Staff training and development were not documented in any formal way to ensure staff were sufficiently supported or meeting their own professional goals. Page 18 of 26

19 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found Our judgement The provider is non-compliant with Outcome 16: Assessing and monitoring the quality of service provision. We have judged that this has a minor impact on people who use the service. Our findings What people who use the service experienced and told us The people we spoke with told us that although they did not participate in any surveys, the practice met their needs. The people we spoke with said they had never had to raise a complaint or concern about the service, but said they would feel comfortable to do so with their dentist or the practice manager. People who use the service felt comfortable to raise a complaint or concern and felt confident that staff would respond. Other evidence We asked the practice manager and principal dentist how they monitor patient satisfaction. We saw a "suggestion box" near the exit where patients could anonymously write submit their comments. The dentist said they don't have much feedback from this source. We were told the practice had not formally surveyed patients, but were planning to implement a satisfaction survey some time in the coming months. The practice did not have an updated complaints and concerns log. The principal dentist told us that complaints were primarily handled verbally and informally. The dentist told us that complaints were not generally documented in a log unless the complaint came to them in writing. The practice's complaints policy stated that complaints or concerns raised "should be recorded," but it did not appear that the practice was following this guideline. Inconsistent documentation of complaints and Page 19 of 26

20 concerns and no effective measurement of patient satisfaction meant that the service was unable to determine their own quality from the viewpoint of their patients. As the practice provided NHS dental services, they were subject to scrutiny from the local Primary Care Trust (PCT). The practice manager told us that the PCT carried out inspections and desktop reviews of Craigweil Dental Practice. The practice did not have a copy of their most recent PCT inspection or Department of Health audit. We spoke with a representative from the PCT who said there were no major patient issues raised about this practice to date. There was an inadequate process for assessing risk. The only clear risk assessments in place related to fire safety and the emergency drugs and oxygen supply. We found no evidence of risk assessments that addressed individual patient needs, other environmental risks including tripping/slipping hazards and infection control. We found no evidence of guidance for staff on how these risks can be reduced by staff. Staff had not received training in risk management. In addition, the risk assessment regarding the emergency drug supply did not identify concerns about controlled drugs being secured in a locked container. This indicated that their system of risk assessment was not working. We viewed an insufficient system of internal auditing. The only audits we were shown included a clinical waste audit from March 2012 and the quality of radiograph images. There were no audits in place to review their infection control procedures, decontamination processes, maintenance of equipment, accuracy of patient medical records, and training. The practice did not have an annual statement of their infection prevention strategy, as outlined by the Department of Health's Code of Practice. In addition, the clinical waste audit did not identify concerns about storage of clinical waste in the same shed with paper patient records. This indicated that their system of clinical waste auditing was not working. The practice was unable to demonstrate their own compliance in the form of documentation or procedures. The principal dentist and the practice manager both commented that they were glad to be having an inspection so they could identify areas of strength and weakness to work on. However, the practice should have their own system of internal assessment to identify potential gaps that need addressing before they are inspected. People who use the service, their representatives and staff were not asked for their views about their care and treatment. The provider sometimes took account of complaints and comments to improve the service, but this system was inconsistent and not documented appropriately. Our judgement The provider did not have an effective system to regularly assess and monitor the quality of service that people received. Page 20 of 26

21 Action we have asked the provider to take Compliance actions The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance. Regulated activity Regulation Outcome Surgical procedures Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 07: Safeguarding people who use services from abuse How the regulation is not being met: People who use the service were not protected from the risk of harm, because the provider had not taken reasonable steps to identify the possibility of harm and prevent it from happening. Risk assessments, staff training in safeguarding, appropriate background checks, complaints and concerns documentation, and clear policies were not in place to ensure patients were protected from risk of harm or abuse. Treatment of disease, disorder or injury Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 07: Safeguarding people who use services from abuse How the regulation is not being met: People who use the service were not protected from the risk of harm, because the provider had not taken reasonable steps to identify the possibility of harm and prevent it from happening. Risk assessments, staff training in safeguarding, appropriate background checks, complaints and concerns documentation, and clear policies were not in place to ensure patients were protected from Page 21 of 26

22 risk of harm or abuse. Surgical procedures Regulation 12 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 08: Cleanliness and infection control How the regulation is not being met: People were not protected from the risk of infection because appropriate guidance and procedures had not be implemented and followed. The practice had some policies and procedures in place around infection control and decontamination, but these policies were not being followed consistently. Current practices by staff present a risk to the spread of infection. In addition, the practice did not have clear methods of documenting and auditing their practices for quality assurance measures. Staff had not been appropriately trained in infection control, health and safety, and decontamination guidance. Treatment of disease, disorder or injury Regulation 12 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 08: Cleanliness and infection control How the regulation is not being met: People were not protected from the risk of infection because appropriate guidance and procedures had not be implemented and followed. The practice had some policies and procedures in place around infection control and decontamination, but these policies were not being followed consistently. Current practices by staff present a risk to the spread of infection. In addition, the practice did not have clear methods of documenting and auditing their practices for quality assurance measures. Staff had not been appropriately trained in infection control, health and safety, and decontamination guidance. Page 22 of 26

23 Surgical procedures Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 14: Supporting staff How the regulation is not being met: People were cared for by staff who were not sufficiently supported to deliver care and treatment safely and to an appropriate standard. Staff training and development were not documented in any formal way to ensure staff were sufficiently supported or meeting their own professional goals. Treatment of disease, disorder or injury Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 14: Supporting staff How the regulation is not being met: People were cared for by staff who were not sufficiently supported to deliver care and treatment safely and to an appropriate standard. Staff training and development were not documented in any formal way to ensure staff were sufficiently supported or meeting their own professional goals. Surgical procedures Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 16: Assessing and monitoring the quality of service provision How the regulation is not being met: The provider did not have an effective system to regularly assess and monitor the quality of service that people received. Treatment of disease, disorder or injury Regulation 10 HSCA 2008 Outcome 16: Assessing and monitoring the Page 23 of 26

24 (Regulated Activities) Regulations 2010 quality of service provision How the regulation is not being met: The provider did not have an effective system to regularly assess and monitor the quality of service that people received. The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us within 14 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete. Page 24 of 26

25 What is a review of compliance? By law, providers of certain adult social care and health 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 Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 25 of 26

26 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) 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. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 26 of 26