The Footmans Cottage Also known as Bridgewater Family Planning Service Association Limited

Updated 27 April 2023

The Footmans Cottage vasectomy service operates from office premises located in Castle Park, Frodsham, Cheshire, WA6 6SB. They are also known by the provider’s name Bridgewater Family Planning Service Association Limited.

They provide vasectomy services to people in Merseyside and Cheshire from four clinic sites which are located in NHS premises. The provider seeks assurance from the host sites that health and safety of the premises is maintained and compliant.

The sites they operate from are:

Victoria Central Health Centre – Mill Lane, Wallasey

Halton General Hospital, Hospital Way, Palacefields, Runcorn

Fingerpost Health Centre, Atlas Street, St Helens

Aintree Teaching Hospital, Lower Lane, Liverpool

These sites were not visited as part of the inspection.

Opening hours/hours of operation:

Monday – Friday 9am – 5pm Office for enquiries

Saturday and Sunday – 9am – 5pm Clinics

The service is registered with CQC under the Health and Social Care 2008 to provide the following Regulated Activities: Surgical procedures.

How we inspected this service

Before visiting we reviewed a range of information we hold about the service and asked the service to send us a range of information. This included the actions taken following the previous inspection, significant events analysed in the last 12 months and the details of staff employed to include their qualifications and proof of registration with their professional bodies. As part of the inspection, we spoke to the registered manager and reviewed a range of documents.

To get to the heart of patients’ experiences of care and treatment, we 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?

At this inspection we focussed on following up the key question of well- led.

Updated 27 April 2023

This service is rated as Good overall. (Previous inspection March 2022 – Good with requires improvement in the key question of well led)

The key question inspected is rated as:

Are services well-led? – Good

We carried out an announced focused inspection at The Footmans Cottage to follow up on breaches of regulations. We followed up on the key question and areas of well led and the breach of Regulation 17.

• At the last inspection (March 2022) we found that the provider must ensure effective governance systems are developed, implemented and monitored to ensure continuous quality assurance and improvement.

We also found that there were areas where the provider should make improvements. These were:

• Implement and monitor a system for demonstrating staff had received appropriate recruitment checks and required training at appropriate intervals.
• Implement and monitor an effective system for reviewing staff training, performance, learning and development needs.
• Appoint an appropriately qualified infection control lead to support the registered manager.

CQC inspected the service on 19 April 2023 and checked these areas as part of this focussed inspection. We found improvements had been made and concerns had been resolved.

The provider Bridgewater Family Planning Service Association Ltd offers surgical vasectomy procedures for clients in Merseyside and Cheshire across four clinics based in NHS premises.

The managing director 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.

Our key findings were:

The provider had demonstrated substantial improvements to quality and governance over the last 12 months. There were plans in place for future developments and service improvements supported by appropriate staffing and infrastructure.

At this inspection we found:

• Effective governance systems had been developed, implemented and embedded. The new systems implemented enhanced continuous quality assurance and improvement.
• Systems ensured reporting, analysing, learning and improvement from significant events and incidents. Evidence demonstrated improvements in practice made as a result.
• Quality monitoring and improvement systems were in place including patient feedback, listening and learning from incidents and complaints and a clinical audit program.
• Recommendations had been acted on and the provider now had effective systems for ensuring staff had received the appropriate recruitment checks, required training and development and appraisals.
• An appropriately qualified clinical lead for infection prevention and control had been appointed.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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