This service is rated as Requires Improvement overall.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Ailsa House on 11 and 12 September 2019 as part of our inspection programme.
The service has a 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 this inspection we found:
- The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes but repeat evidence of incidents was found to indicate that dissemination of learning to the entire staff work-force was not adequate.
- 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.
- The service completed audits but we found limited evidence of disease-specific audits.
- On review of the service’s performance data, we found the service was not in line with expected national targets.
- Full compliance with staff training could not be established, particularly in relation to clinical staff training records.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Staff felt respected and well looked after by the service, in line with the service’s values.
- Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- The provider worked in partnership with external stakeholders to develop its services and identify ways to improve.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
The areas where the provider should make improvements are:
- Review how audits are undertaken so they are appropriate, relevant and help drive improvement.
- Continue to review patient feedback to identify areas for improvement.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care