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Overview
Complete
Clearfield Medical Center / Acute Wards for Adults of Working Age / 21 Jun 2019
Care Quality Commission (CQC) Inspection Checklist
Inspection score
52.78%
Failed items
17
Created actions
1
Site
Manila
Health/Social Care Facility
Clearfield Medical Center
Location
115 Preston Rd., Morestead SO21 9RJ
Health/Social Care Service
Acute Wards for Adults of Working Age
Head of Assurance, Compliance & Quality
Nicolette Cendana
Conducted on

21st Jun, 2019

7:38 PM +08

Failed items
17
CQC Inspection Checklist / Safe
Do systems, processes and practices protect people from abuse, neglect, harassment, and breaches of their dignity and respect? Are these monitored and improved?
No
Notes
monitored, but not yet improved
CQC Inspection Checklist / Safe
Is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks?
No
Notes
not as much in ongoing checks
CQC Inspection Checklist / Safe
Do the design, maintenance and use of facilities and premises keep people safe?
No
Photos
CQC Inspection Checklist / Safe
Are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?
No
Notes
assessed but not consistently monitored, needs to be updated
CQC Inspection Checklist / Safe
Are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?
No
Photos
CQC Inspection Checklist / Safe
Do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?
No
Photos
CQC Inspection Checklist / Safe
Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively?
No
Actions
To do
Create risk management plans
CQC Inspection Checklist / Safe
Do staff identify and respond appropriately to changing risks to people, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges?
No
Photos
CQC Inspection Checklist / Safe
Is the impact on safety assessed and monitored when carrying out changes to the service or the staff?
No
Notes
monitored, but not correctly assessed
CQC Inspection Checklist / Safe
Do staff have all the information they need to deliver safe care and treatment to people?
No
CQC Inspection Checklist / Safe
Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way?
No
CQC Inspection Checklist / Safe
When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?
No
CQC Inspection Checklist / Safe
Are medicines and medicines-related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.)
No
CQC Inspection Checklist / Safe
Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?
No
Notes
not reviewed regularly
CQC Inspection Checklist / Safe
Does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?
No
CQC Inspection Checklist / Safe
Is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?
No
Photos
CQC Inspection Checklist / Safe
Are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews effective?
No
Actions
1
CQC Inspection Checklist
17
1
52.78%
This is only a sample report from a section of the CQC inspection checklist by iAuditor.
Safe
17
1
52.78%
Do systems, processes and practices keep people safe and safeguarded from abuse?
Yes
Are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?
Yes
Do systems, processes and practices protect people from abuse, neglect, harassment, and breaches of their dignity and respect? Are these monitored and improved?
No
Notes
monitored, but not yet improved
Are people protected from discrimination, which might amount to abuse or cause psychological harm? (This includes harassment and discrimination in relation to protected characteristics under the Equality Act.)
Yes
Is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks?
No
Notes
not as much in ongoing checks
Do staff receive effective training in safety systems, processes and practices?
Yes
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Do staff understand their responsibilities and adhere to safeguarding policies and procedures, including working in partnership with other agencies?
Yes
Do staff identify adults and children at risk of, or suffering, significant harm?
Yes
Do the design, maintenance and use of facilities and premises keep people safe?
No
Photos
Are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?
No
Notes
assessed but not consistently monitored, needs to be updated
Are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?
No
Photos
Do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?
No
Photos
Do arrangements for using bank, agency and locum staff keep people safe at all times?
Yes
Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively?
No
Actions
To do
Create risk management plans
Do staff identify and respond appropriately to changing risks to people, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges?
No
Photos
Is the impact on safety assessed and monitored when carrying out changes to the service or the staff?
No
Notes
monitored, but not correctly assessed
Do staff have all the information they need to deliver safe care and treatment to people?
No
Are people’s individual care records, including clinical data, written and managed in a way that keeps people safe?
Yes
Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way?
No
When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?
No
Do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment?
Yes
Does the provider ensure the proper and safe use of medicines, where the service is responsible?
Yes
Are medicines and medicines-related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.)
No
Are medicines appropriately prescribed, administered and/or supplied to people in line with the relevant legislation, current national guidance or best available evidence?
Yes
Do people receive specific advice about their medicines in line with current national guidance or evidence?
Yes
Does the service make sure that people receive their medicines as intended, and is this recorded appropriately?
Yes
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Are people's medicines reconciled in line with current national guidance when transferring between locations or changing levels of care?
Yes
Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence?
Yes
Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?
No
Notes
not reviewed regularly
Does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?
No
What is the track record on safety?
Our hospital-associated infection rates increased, so our housekeeping practices in acute wards need to improve. Routine cleaning should emphasize on high-touch surfaces and terminal cleaning should be performed effectively.
What is the safety performance over time?
We started out great, but over time, we have lacked in monitoring data consistently. This made it more difficult for us to see where we need to improve.
How does safety performance compare with other similar services?
Current safety performance requires a lot of improvement, especially in performing assessments correctly and monitoring data consistently.
How well is safety monitored using information from a range of sources (including performance against safety goals where appropriate)?
Not so well, we need a better safety management system like iAuditor to help us achieve our safety goals.
Are lessons learned and improvements made when things go wrong?
Yes
Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?
Yes
Are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?
Yes
Are lessons learned and themes identified, and is action taken as a result of investigations when things go wrong?
Yes
Is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?
No
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Are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews effective?
No
Completion
Additional Observations
In order to get outstanding ratings, we need to provide safer care by consistently monitoring risk assessments and improving our safety management system with iAuditor.
Head of Assurance, Compliance & Quality
Nicolette Cendana
24th Jun, 2019 12:18 PM +08
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