We carried out an announced comprehensive inspection on 17 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Our key findings were:

• The provider had systems in place to manage incidents and significant events.
• The service had clear systems to keep patients safe and safeguarded from abuse. There was an effective system in place to obtain consent from persons with parental responsibility.
• Risks to patients were assessed and managed. The service held emergency medicines and equipment.
• Policies and procedures were in place to govern relevant areas and they were updated regularly.
• The clinical lead assessed patients’ needs and delivered care in line with current evidence based guidance. There was evidence of clinical audits undertaken to improve outcomes for patients.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand. A website for the clinic was under development in response to feedback about increasing awareness of the service in the community.

• Written information was provided to the parents of patients detailing how to care for the patient following surgery.
• The provider had good facilities and was well equipped to treat patients and meet their needs.
• The provider actively sought feedback from patients through various methods and acted on the feedback to improve user experience.
• The provider was aware of and complied with the requirements of the Duty of Candour.

Some areas where the provider should consider improvements are:

• Develop an appraisal system to support the development of staff.
• Improve the recording of minutes of meetings undertaken with staff.
• Develop the provision of information in other languages for patients who may have limited knowledge of the English language.