Brierley Hill Health and Social Care Centre

Updated 25 May 2017

We carried out an announced inspection on 7 December 2016. There were two CQC inspectors, who had access to advice from a specialist advisor.

Before the inspection, we gathered information from previous inspections; the latest was 5 March 2014. The service was inspected in 2014 against the essential standards of: care and welfare of people who use services, management of medicines, assessing and monitoring the quality of service provision, and complaints. The service met all of the standards; however, we found during that inspection, the service required some improvement in the auditing of medication stored on the premises.

We reviewed safeguarding alerts and concerns, notifications of never events, deaths, and serious incidents, and deprivation of liberty safeguards (DoLS). There were no instances of any of these occurrences.

We asked the provider for their complaints, referral to treatment times, audits, appraisal information, and patient and staff surveys. We will present this information in the detailed findings section of the report.

We performed the inspection over one day. We carried out observations of care; we talked to three patients and one relative. We interviewed the three members of staff, observed the pre and post-procedure consultations, and reviewed three sets of records.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 25 May 2017

We carried out an announced comprehensive inspection on 7 December to Brierley Hill additional community services vasectomy clinic 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 providing well-led care in accordance with the relevant regulations.

Background

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.

Additional Community Services Ltd provides this service, which comprises a one-stop shop approach for vasectomy for adult men in Brierley Hill. The service is funded through the NHS. This means the service offers a pre-procedure consultation, followed by the procedure on the day and a post-procedure consultation regarding aftercare. Men may wish to defer the procedure to another date if they feel unsure about going ahead on the day. The service offers 35 appointments per month, booked following a GP consultation on the electronic patient appointment booking system (choose and book). Appointments are available every Wednesday and one Saturday per month. A GP who is trained to carry out no scalpel vasectomy procedures runs the service, supported by health care assistants and an administrator.

The doctor carrying out the procedure 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.

Three people provided feedback about the service at the time of the inspection. They all said that they were happy with the information they had received, and the quality of the service on the day. Patients had not completed any comment cards.

Our key findings were:

• Safe one-stop procedures, including pre-procedure consultation, procedure and post-procedure education.
• Good infection control practices.
• Clear written and verbal information regarding consent and the procedure and outcomes.
• Good evidence of risk management being undertaken for each patient.
• Effective monitoring of patient outcomes.
• Good access with no waiting.
• No complaints and good monitoring of patient satisfaction.
• Well-led with a clear focus on service delivery.
• Good communication channels and governance processes.
• The doctor for the service was a trainer for other no-scalpel vasectomists

There were areas where the provider could make improvements and should:

• Review the recording of lidocaine stock to ensure a permanent record of all deliveries received.