Illumina Diagnostics

• 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.