We carried out an announced comprehensive inspection on 24 September 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?
Our findings were:
Are services safe?
We found that this service was providing safe care in accordance with the relevant regulations
Are services effective?
We found that this service was providing effective care in accordance with the relevant regulations
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations
Are services responsive?
We found that this service was providing responsive care in accordance with the relevant regulations
Are services well-led?
We found that this service was not providing well-led care in accordance with the relevant regulations
This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Ultra Sports Clinic provides physiotherapy, chiropractic services, biokinetics and sports massage. Therefore, we did not inspect or report on these services.
The clinic offers radiography and ultrasound guided injections provided by a consultant radiologist which are activities covered by CQC regulations.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
The service lead is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We reviewed 35 CQC patient comment cards, all of which were exclusively positive about the service provided. The comment cards stated that staff were caring and considerate and the treatment provided by the service was of a high standard.
Our key findings were:
- There was a system in place for acting on significant events.
- Risks associated with the premises and the delivery of care and treatment were well managed. However, the service did not have adequate arrangements in place to respond to medical emergencies. The service took action after our inspection to address this.
- There were arrangements in place to protect children and vulnerable adults for abuse.
- The service had not completed comprehensive pre employment checks for all staff and did not have full oversight of staff training.
- Care and treatment was provided in accordance with current guidelines.
- Patient feedback indicated that staff were compassionate, the care provided of a high standard and that it was easy to access appointments.
- The service had a system to receive and respond to complaints.
- There was a clear vision and strategy and staff spoke of an open and supportive culture. There was effective governance in most areas to ensure risks were addressed and patients were kept safe.
There were areas where the provider needs to make improvements and must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
There were areas where the provider could make improvements and should:
-
Continue with plans to undertake formal quality monitoring and improvement activity in respect of the regulated activity.
-
Continue with plans to undertake formal engagement with patients to obtain feedback which is then utilised to improve services.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice