Leeds Screening Centre

Updated 8 February 2022

Leeds Screening Centre is registered for the regulated activity of diagnostic imaging and treatment of disease, disorder or injury. Patients can either contact the clinic directly to book an appointment or be referred by either a GP or other provider.

Leeds Screening Centre carries out ultrasound procedures, pregnancy scans and blood screening.

The clinic has a registered manager who has been in post since the clinic opened in 2015.

This is our first inspection of Leeds Screening Centre at this location.

What people who use the service say

We looked at reviews of the service on social media and asked the service for their latest patient survey results. There were a limited number of reviews relating to the previous 12 months on social media.

Leeds Screening Centre had received mostly positive feedback about the care and treatment people received at the clinic in the past 12 months both online and from their internal patient satisfaction survey.

Most patients made comments about how well they were looked after and how professional, kind and caring staff were throughout consultations and procedures however some patients said they were disappointed by the service they received because they felt rushed or had a long wait once in attendance.

Updated 8 February 2022

This is our first inspection of this location. We rated it as requires improvement because:

• We had concerns about aspects of infection prevention and control (IPC) in the service such as the location of the only sink, the use of alcohol gel rather than handwashing as the primary method of hand decontamination, disposal of clinical waste, open top bins and the location of the sharps bin. Additionally, some chairs and beds had deteriorated and did not meet IPC standards because they could not be properly cleaned.
• The provider kept staff files, but these were not all up to date and did not all contain the full information required to demonstrate a robust recruitment process had been undertaken.
• Not all staff were confident about who to contact in the event of a safeguarding concern, staff had not undergone training about recognising domestic violence and the safeguarding lead did not meet intercollegiate standards with the level of safeguarding training they had undergone.
• Some patients commented and we saw that there were no blinds or curtains in place around beds to protect the privacy and dignity of patients.
• Some staff were unclear about what incidents and near misses they should report to the management team although there was a policy for staff to refer to.
• The service did not have a robust process for supporting patients whose first language was not English and who needed an interpreter or signer. The service did not have a process in place to make sure information passed on to patients by nonprofessional interpreters was accurate and complete.
• The provider was not able to provide quality checked leaflets in languages other than English.
• The provider did not have a specific policy in place to support staff managing patients who had additional support needs such as a learning disability, sensory impairment or dementia.
• Meeting minutes were not comprehensive and did not detail discussions or actions taken during meetings. They were not a clear record of meetings.
• There were breaches in regulations and risks within the service that had not been identified by the management team. Therefore, there was no mitigation in place to reduce risks or address regulation breaches.

However:

• The provider was able to show us policies, procedures, risk assessments and standard operating procedures they used to make sure patients were safe from the risk of harm.
• There was information for staff working at the service about their responsibilities in relation to clinical records and clinical records contained sufficient information to make sure patients were safe.
• Staff who worked for the service had the appropriate qualifications, skills and experience to make sure patients received care and treatment that was safe.
• There was a process in place to assure the provider that staff had an up to date registration and revalidation.
• The building was easy to access for those with a disability.
• Cleaning equipment and substances hazardous to health were locked away.
• Portable appliance testing (PAT), servicing and calibration, were completed and up to date.
• The provider was able to assure us that staff followed the correct process to obtain patient consent.
• Staff received annual appraisals and could access training to make sure their knowledge remained up to date. Staff training was up to date and there was a training plan in place for all staff.
• The provider gathered feedback from patients about their experiences of the service.
• There was information about how to make complaints displayed and the manager of the service dealt with complaints. Lessons learned were fed back to staff at quarterly staff meetings.
• Social media feedback and feedback gathered by the provider was predominantly positive and patients felt cared for, well informed, supported and involved in the care and treatment they received.
• There were governance processes in place, and these included how the provider monitored performance to ensure care and treatment was delivered in line with national guidance and work to improve the services delivered to patients.
• Clinical audit was carried out. Although this had been limited in the past 12 months because of the pandemic, the manager had plans in place for the coming 12 months which would see this increase.
• The provider worked closely with local NHS trusts to provide services in a joined up cohesive way and there were systems in place to monitor contracts and the quality of services delivered.

Updated 8 February 2022

We rated it as requires improvement because:

• There was a lack of evidence that all staff understood how to protect patients from abuse or identify those at risk of abuse including domestic violence. The service did not control infection risk well. The service had a process in place to manage safety incidents and learn lessons from them however some staff were not confident about the type of things they should report. Recruitment records did not demonstrate robust recruitment processes. The service had enough staff to care for patients.
• There was evidence to show staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. There was evidence staff supported patients to make decisions about their care. Services were available by appointment only. Staff worked together for the benefit of patients.
• The service planned care to meet the needs of their patients and took account of patients’ individual needs however if a patient’s first language was not English the service often used online translation applications to communicate which increased risks to patients. There was a process for people to give feedback. People could only access the service by appointment but did not have to wait too long for treatment.
• Leaders ran services using reliable information systems however there were risks and regulation breaches which the leadership team had not identified and were therefore left unmitigated and not addressed. Staff were supported to develop their skills. There was clarity from the provider about staff roles and accountabilities. The service had engaged with stakeholders to plan and manage services.

We rated this service as requires improvement overall because we found safe and well led to require improvement. We rated effective, caring and responsive as good.