Sussex Osteoporosis Clinic

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out this announced comprehensive inspection of Sussex Osteoporosis Clinic on 3 November 2022, under Section 60 of the Health and Social Care Act 2008. 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. This was the provider’s first inspection of the service since it registered with the Care Quality Commission (CQC).

How we carried out the inspection:

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Speaking with staff in person, on the telephone and using video conferencing facilities.
• Requesting documentary evidence from the provider.
• A site visit.

We carried out an announced site visit to the service on 3 November 2022. Prior to our visit we requested documentary evidence electronically from the provider. We spoke to staff on the telephone and using video conferencing facilities prior to our site visit.

Sussex Osteoporosis Clinic is an independent provider of NHS commissioned bone density (DEXA) scanning services, for the diagnosis of osteoporosis. This service is registered with CQC under the Health and Social Care Act 2008 in respect of the services it provides.

Sussex Osteoporosis Clinic is registered with the Care Quality Commission to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening procedures; Surgical procedures; Family planning; Services in slimming clinics.

The service employs two operations managers who are the registered managers. 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.

Our key findings were:

• There were safeguarding systems and processes to keep people safe. All staff had completed some training in the safeguarding of children and vulnerable adults. Some staff required additional training, at an appropriate level to support their role, in line with current guidance.
• Arrangements for chaperoning were effectively managed.
• There were records to demonstrate recruitment checks had been carried out in accordance with regulations.
• There were processes in place for the induction of staff and monitoring of role-specific competencies.
• There were governance and monitoring processes to provide assurance to leaders that premises they were leasing were safe and suitable for use. However, we identified one instance whereby risks associated with legionella bacteria had not been fully monitored.
• There were clear and comprehensive DEXA scanning and reporting protocols, local rules and radiation risk assessments in place.
• There were processes to assess the risk of, and prevent, detect and control the spread of infection.
• There were effective processes in place for the management of incoming referrals and processes to support the tracking of patients to ensure their timely access to treatment.
• There was evidence of monitoring and auditing of patient outcomes, in line with agreed key performance indicators.
• There were effective governance, incident reporting and risk assessment processes in most areas. However, some staff were unclear about documentary incident reporting processes.
• There was effective communication and information sharing amongst the staff team.
• Staff were subject to regular review of their performance and felt well supported by managers.
• Service users were asked to provide feedback on the service they had received, and the service acted promptly to respond to and share feedback with the team.
• Complaints were managed appropriately.

The areas where the provider should make improvements are:

• Continue to review processes to ensure all staff complete training in the safeguarding of children and vulnerable adults at an appropriate level to support their role.
• Review health and safety premises information received from the host practice to fully monitor potential risks relevant to staff and patients.
• Obtain evidence of certification of completed training for all clinical staff.
• Improve staff awareness of incident reporting templates.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services