Unit 4 Cornishway Industrial Estate

Independent Ambulance · North West

Overall Rating
Requires Improvement Last inspected 7 July 2022
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

10 must-do actions
6 should-do actions

Must-Do Actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
Ensure they assess the risks to the health and safety of service of people usingservices. That risk assessments are available and completed by people with the qualifications, skills, competence and experience to do so.
Regulation 12 (1)(2)(a) Safe care and treatment
The provider did not ensure the risks to the health and safety of people using services were properly assessed by people with the qualifications, skills, competence and experience to do so.
Must Do
Safe
Ensure they complete risks assessments doing all that is reasonably practicable to mitigate identified risks to patients.
Regulation 12 (1)(2)(b) Safe care and treatment
The provider did not ensure they mitigated identified risks to patients.
Must Do
Safe
Provide care and treatment in a safe way for service users by assessing the risk of, and preventing, detecting and controlling the spread of, infections.
Regulation 12 (1)(2)(h) Safe care and treatment
The provider did not ensure care and treatment were provided in a safe way for service users by assessing the risk of, and preventing, detecting and controlling the spread of, infections.
Must Do
Safe
Ensure incidents that affect the health, safety and welfare of people using services are appropriately recognised and reported. Incidents must be reviewed and thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the situation and make sure that improvements are made as a result.
Regulation 12 (1)(2)(c)
The provider did not ensure incidents that affect the health, safety and welfare of people using services were appropriately recognised, reported, reviewed and acted on to reduce risk.
Must Do
Safe
Provide care and treatment in a safe way for service users by ensuring the proper and safe management of medicines. Staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept under review. Staff must follow policies and procedures about managing medicines.
Regulation 12 (1)(2)(g) Safe care and treatment
The provider did not provide care and treatment in a safe way for service users by ensuring the proper and safe management of medicines. Not all staff were suitably trained and competent. Staff did not always follow policy and procedure in relation to medicine's management.
Must Do
Safe
Ensure all premises and equipment are clean, suitable for the purpose for which they are to be used and properly maintained.
Regulation 15 (1)(a)(b)(e)
The provider did not ensure all premises and equipment were clean, suitable for the purpose for which they are to be used and properly maintained.Regulation15(1)(a)(b)(e)Premisesandequipment.
Must Do
Well-led
Establish and operate effectively systems and process to identify where quality and/or safety are being compromised and to respond appropriately to assess, monitor and improve the quality and safety of the services
17 (1)(2)(a) Good Governance
The provider did not establish and operate effective systems and process to identify where quality and/or safety were being compromised and to respond appropriately to assess, monitor and improve the quality and safety of the services17(1)(2)(a)GoodGovernance.
Must Do
Effective
The provider must ensure that staff are competent, receives such appropriate training, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Regulation 18 (1)(2)(a) Staffing
The provider did not ensure that staff were competent and received such appropriate training, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.Regulation18(1)(2)(a)Staffing.
Must Do
Well-led
Ensure that procedures are be established and operated effectively to ensure staff employed are of good character and have the competence, skills and experience for the work to be performed by them,
Regulation 19 (1)(2)(a)(b) Fit and proper persons employed.
The provider did not ensure that procedures were be established and operated effectively to ensure staff employed were of good character and had the competence, skills and experience for the work to be performed by them,Regulation19(1)(2)(a)(b)Fitandproperpersonsemployed.
Must Do
Well-led
Maintain securely records of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided;
17 (1)(2)(d) Good Governance.
Staff kept records of patients’ care and treatment. Records were not always stored securely.

Should-Do Actions (6)

Recommended improvements to enhance service quality.

Should Do
Safe
Operate a cleaning schedule and monitor the level of cleanliness. To take action without delay when any shortfalls are identified and make sure that staff with responsibility for cleaning have appropriate training
Should Do
Safe
Operate a stock control system to monitor single use items and ensure that they remain in date
Should Do
Effective
Review arrangements for staff to receive training in the deteriorating patient such as NEWS2 in line with the services own policies
Should Do
Well-led
Review the risk register to have oversight of all risks within the organisation, covering all areas of practice, and monitor progress against them. Determine and implement an operation means to determine and review on an ongoing basis with appropriate planning any risks identified on the risk register
Should Do
Well-led
Review policies and standard operating procedures to determine I they reflect the service delivered and monitor performance against any policies
Should Do
Effective
Maintain an up to date system to identify HCP staff, their qualifications and training.
Location Details
CQC ID: 1-10325024809
Local Authority: Manchester
Region: North West
Inspection Report
Type: Comprehensive inspection
Date: 7 July 2022
Rating: Requires Improvement
Actions: 10 must-do , 6 should-do
AI-extracted 17 Feb 2026