Eccleshill Treatment Centre

Updated 4 February 2022

The Eccleshill Treatment Centre is registered to provide care and treatment for people requiring diagnostic procedures, surgery and treatment of disease, disorder or injury, on a day case basis with no overnight stay.

The provider is registered to provide the following regulated activities:

• surgical procedures

• Treatment of disease, disorder or injury

• diagnostic and screening procedures

The provider has a manager registered with CQC.

This was the first time the service has been inspected.

The main service provided by this provider was medicine services, being endoscopy procedures. Where our findings on outpatients and surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the medicine service.

Updated 4 February 2022

We rated this location as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They involved patients and families and carers in care decisions.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

However:

• The vision and values were not embedded and there was no strategy with key performance indicators to support monitoring of the delivery of the vision;
• The culture around staff challenging poor practice required further embedding. For example, we found two instances where staff could have challenged poor practice but did not do so.
• Documented governance of outpatients, except for perhaps endoscopy related outpatient services, was absent. It appeared all governance of outpatients was operated through the endoscopy end-users meetings. Outpatients lacked a focussed governance meeting forum.
• We found there was no effective risk management policy and the risks we found on inspection did not match the risks on the service’s risk register.
• Information management required improvement. For example, we found a major breach of good practice in information governance.

Updated 4 February 2022

We rated this location as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed most medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff engaged in clinical audit to evaluate the quality of care they provided. staff worked well together as a multidisciplinary team.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Endoscopy services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers and involved them in care decisions.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and people were able to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Not all medicines were stored safely with temperature controls in place where medicines were kept in places other than regular medicine storage environments. Not all substances hazardous to health were stored securely. Not all stock was well managed or stored effectively. We found medical records did not always contain personal information relevant only to the named patient.
• The telephone preassessment process for endoscopy patients was not always completed thoroughly and there was no audit process to check staff and records identified relevant risks to patients prior to procedures.
• There were no leaflets or information displayed in patient areas about how to raise a concern or complaint.
• Leaders, but not all staff understood the service’s vision and values, and how to apply them in their work.
• The service’s internal governance processes, policies and documentation were not always available to provide managers with assurance on all aspects of performance and risk.
• Staff files were not all complete and did not meet requirements to grant practising privileges or to meet the fit and proper person’s requirement for directors and senior managers (Regulation 5(2)).

The main service provided by this provider was medicine services, being endoscopy procedures. Where our findings on outpatients and surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the medicine service.

Updated 4 February 2022

We rated this location as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They involved patients and families and carers in care decisions.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

However:

• The vision and values were not embedded and there was no strategy with key performance indicators to support monitoring of the delivery of the vision;
• The culture around staff challenging poor practice required further embedding. For example, we found two instances where staff could have challenged poor practice but did not do so.
• Documented governance of outpatients, except for perhaps endoscopy related outpatient services, was absent. It appeared all governance of outpatients was operated through the endoscopy end-users meetings. Outpatients lacked a focussed governance meeting forum.
• We found there was no effective risk management policy and the risks we found on inspection did not match the risks on the service’s risk register.
• Information management required improvement. For example, we found a major breach of good practice in information governance.

The main service provided by this provider was medicine services, being endoscopy procedures. Where our findings on outpatients and surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the medicine service.

Updated 4 February 2022

We rated this location as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled most infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff engaged in clinical audit to evaluate the quality of care they provided. staff worked well together as a multidisciplinary team.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers and involved them in care decisions.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and people were able to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The service did not have a robust process to check the cleanliness and state of its premises.
• Not all substances hazardous to health were stored securely. Not all stock was well managed or stored effectively. We found medical records did not always contain personal information relevant only to the named patient.
• There were no leaflets or information displayed in patient areas about how to raise a concern or complaint.
• Not all staff understood the service’s vision and values, and how to apply them in their work. The service’s internal governance processes, policies and documentation were not always available to provide managers with assurance on all aspects of performance and risk. Staff files were not all complete and did not meet requirements to grant practising privileges or meet the fit and proper person’s requirement for directors and senior managers.

The main service provided by this provider was medicine services, being endoscopy procedures. Where our findings on outpatients and surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the medicine service.