26 July and 1 August 2023
During an inspection looking at part of the service
The service had previously been inspected on 25 and 26 August 2022. In this inspection the service was rated as good overall, but requires improvement in the safe key question, and found to be in breach of regulation 12 of the Health and Social Care Act 2008.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for LCW UCC (St Charles Centre for Health and Wellbeing) on our website at www.cqc.org.uk
We carried out this announced focused inspection of LCW UCC (St Charles Centre for Health and Wellbeing) on 26 July and 1 August 2023. We found that some of the breaches of regulation from the previous inspection had been fully addressed, but in one area there was more to do. Following this inspection, the key questions are rated as:
Are services safe? – Requires improvement.
The registered manager is the Chief Executive Officer. 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 had developed systems such that learning from incidents and safeguarding processes were shared with all staff at the service.
- The service was not meeting targets for ensuring that calls were answered in a timely manner, and abandoned calls avoided. These targets are measured to ensure that safe care is provided.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure that care and treatment is provided in a safe way to patients.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care