• Hospital
  • Independent hospital

Illumina Diagnostics

Overall: Good read more about inspection ratings

Pilgrim Primary Care Centre, Pelham Road, Immingham, Lincolnshire, DN40 1JW (01469) 570729

Provided and run by:
Illumina Diagnostics Ltd

Latest inspection summary

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Background to this inspection

Updated 29 July 2022

Illumina Diagnostics is managed by Illumina Diagnostics Limited. The service provides a Non-Obstetric Ultrasound Service (NOUS) in the community, based in primary care centres across North East and North Lincolnshire covering population of over 300,000. In addition, an Ultrasound Guided Injection service also based in primary care centres is provided across North East Lincolnshire and Grimsby. The service provided services to those patients over the age of 18 years. During the inspection we visited the Pilgrim Primary Care Centre and Freshney Green Primary Care Centre.

Pilgrim Primary Care Centre is a purpose build medical centre and is the main centre registered to provide this service. The centre houses a GP (General Practitioner) Practice as well as a broad range of community delivered services. The building is fully compliant with Equality Act.

The service will eventually provide services through eight satellite centres and a mobile ultrasound across Lincolnshire and Humber. Currently, two satellite centres only are operating and are Freshney Green Primary Care Centre in Grimsby and the Ironstone Centre, which is based in Scunthorpe, South Humberside.

Currently the service operates from Pilgrim Primary Care Centre on Tuesdays, Freshney Green Primary Care Centre Monday to Friday and at Ironstone Centre five days a week.

The registered manager and nominated individual are supported by the Illumina leadership team which comprise of eight experienced individuals whose experience range from that of a GP (General Practitioner), administration and finance. Included within this team are two specialists a consultant orthopaedic surgeon and consultant radiologist. A total of seven sonographers support the team; three male and four female sonographers. The service could also access medical GP support through the Pilgrim Primary Care Centre.

The hospital is registered to provide the following regulated activity:

  • Diagnostic and screening procedure
  • Treatment of disease, disorder, or injury

The hospital has a manager registered with the Care Quality Commission (CQC).

This is the hospitals first inspection since registration on the 8 January 2021. A community-based ultrasound service is provided.

Overall inspection

Good

Updated 29 July 2022

  • The service had enough staff to care for patients and keep them safe. Staff had training in most key skills, understood how to protect patients from abuse, and managed safety well. The service did not have agreed systems and processes in place to safely prescribe, administer, record and store medicines. Infection risk and safety incidents were well managed. The service had a robust process for safety incidents and lessons learned were embedded in practice.
  • Staff provided safe care and treatment and made patients comfortable when needed. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to useful 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 and carers.
  • The service planned care to meet patients’ individual needs and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Governance processes were in place, however, we found that the audit processes for some areas needed further development. 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 to plan and manage services and all staff were committed to improving services continually.

However:

  • The Pilgrim Primary Medical Centre resuscitation trolley was an open trolley and not lockable.
  • A written procedure for the frequency of resuscitation trolley, blood monitoring kits and anaphylaxis kits checks, and accountabilities was not in place.
  • Monitoring of the frequency of resuscitation trolley blood monitoring kits and anaphylaxis kits checks was not in place.
  • Two Legionella risk assessments action plans were not signed to confirm the actions were implemented.
  • Two of the external yellow clinical waste bins locks were broken at Pilgrim Primary Medical Centre.
  • Three COSHH risk assessment was not signed and dated.
  • ‘Pause and Check’ audits were not completed.
  • ‘Surgical Safety’ audits were not completed.
  • An annual audit plan was not in place.
  • There was limited medicines governance and oversight of medicines processes.
  • A medicines management policy and independent prescribing policy was not in place.
  • Medicines were left on the worktop and the medicines cupboard and door entry to the treatment room were seen to be unlocked.
  • Two agency sonographers allied health profession registrations had expired on the 28 February 2022.
  • The service level agreement with the sonographer had expired on the 28 February 2022.