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? – Requires improvement
We carried out an announced comprehensive inspection at The Footmans Cottage as part of our inspection programme. This location had not been inspected previously since registration.
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.
At the time of the inspection there were no patients attending or receiving regulated services and we were unable to ask them about the service. However, we reviewed some comments from patients the service had received online and one written piece of feedback.
Our key findings were:
- Patients received detailed and clear information about their proposed treatment which enabled them to make an informed decision. This included costs (where applicable), risks and benefits of treatment.
- Peri operative care and advice was clear and post-operative support was available.
- Patients were offered appointments at a time convenient to them and treatment was offered in a timely manner.
- Patients’ needs were fully assessed, and care and treatment was tailored to individual needs.
- Clinicians assessed patients according to appropriate guidance, legislation and standards and delivered care and treatment in line with current evidence-based guidance.
- Information about services and how to complain was available and easy to understand.
- There were sufficient staff who were suitably qualified and trained. However, systems for monitoring staff performance and training and development needs should be improved.
- There was not an effective governance framework in place in order to gain feedback or to assess, monitor and improve the quality of the services provided.
- The provider was aware of the requirements of the Duty of Candour.
The areas where the provider must make improvements as they are in breach of regulations are:
- The provider must ensure effective governance systems are developed, implemented and monitored to ensure continuous quality assurance and improvement.
You can see full details of the regulations not being met at the end of this report
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- 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.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care