Downham Health & Leisure Centre

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

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 Downham Health & Leisure Centre. This was the first rated inspection for the service that was registered with the Care Quality Commission (CQC) in 2017. During this inspection we inspected the safe, effective, caring, responsive and well-led key questions.

Downham Health & Leisure Centre is an independent healthcare organisation run by One Health Lewisham (OHL), an integrated community service provider which delivers a number of services for NHS GP practices, across south-east London.

Downham Health & Leisure Centre is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Therefore, we did not inspect or report on these services.

The Chief Operating officer of One Health Lewisham 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 service delivered care and diagnostic procedures from health hubs and from satellite clinics, in spaces run by NHS GP providers.

• There were systems to assess, monitor and manage risks to patient safety. Where these were managed by the service, they generally worked well but they were not consistently effective. For example, not all staff had completed required training to maintain knowledge and skills. We found three members of staff had not completed safeguarding training.

• There was no effective system to ensure that staff employed by host community services, that patients interacted with, had the appropriate skills, knowledge and experience and there were no checks to verify the effectiveness of the system.
• The service had systems and processes to ensure that the premises used to provide services were safe. We visited three host community service sites and looked at equipment and premises, and at documents and found these were generally well managed. However, the provider had no written agreements in place for monitoring host community service risk assessments.
• There were safe procedures for managing medical emergencies including access to emergency medicines and equipment.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.

• We found most recruitment checks were carried out in accordance with regulations (including for agency staff and locums). However, we found some gaps in recruitment records. The provider did not have a written agreement with the host community services that described the recruitment checks expected for staff that interacted with the patients at host clinic sites. There was no mechanism to ensure that this process for ensuring appropriate recruitment checks was effective.

• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
• The service took complaints and concerns seriously and responded to them to improve the quality of care.
• Leaders had the capacity and skills to deliver high-quality, sustainable care. The provider was aware of areas of weaknesses and worked to improve them.
• The service had a culture of high-quality sustainable care.

The areas where the provider should make improvements are:

• Carry out an annual appraisal for all staff.
• Train all staff who act as chaperones.

• Continue to ensure policies and procedures are followed, for example the appraisal policy.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care