NATIONAL ASSEMBLY FOR WALES HEALTHCARE INSPECTORATE WALES
Care Standards Act 2000
INSPECTION REPORT Private and Voluntary Healthcare
O2 Therapy Centres Ltd 16-18 St. Lukes Court, Winch Wen Industrial Estate Swansea SA1 7ER
Date of Inspection: 18th September 2006
You may reproduce this Report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of the National Assembly for Wales.
Regulation Team Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road, Caerphilly, CF83 3ED
INSPECTION REPORT Inspection Episode:
April 2006 to March 2007
Healthcare Provision:
O2 Therapy Centres Ltd
Contact telephone number:
01792 701342
Registered Provider:
O2 Therapy Centres Ltd
Registered Manager:
Mrs Gillian Lewis
Number of places:
None
Category:
Independent Hospital
Date of first registration:
February 2006
Date of publication of this report:
15th November 2006
Date of previous published report: None Lead Inspector:
P Price
Specialist Inspectors/Advisors:
M Warsop T Tilley
PP/LB/02TherapyCtr/0607
2
GUIDELINES ON INSPECTION INTRODUCTION This report has been compiled following an inspection of the home undertaken by the Healthcare Inspectorate for Wales (HIW) under the provisions of the Care Standards Act 2000 and associated Regulations. The primary focus of the report is to comment on the quality of life and quality of care experienced by service users. The report contains information on the process of inspection and records its outcomes. The report is divided into nine distinct parts reflecting the broad areas of the National Minimum Standards. An overall conclusion of the home’s compliance with Private and Voluntary Healthcare (Wales) Regulations 2002 is recorded. The HIW’s Inspectors are authorised to enter and inspect care homes at any time. At each inspection episode or period there are visit/s to the service in addition to a range of other activities such discussion groups, self- assessment and the use of questionnaires. HIW try to find the best way of capturing patients, their relative/representatives and staff employed within the service experiences. At any other time throughout the year visits may also be made to the service to investigate complaints and in response to changes in the home. Inspection enables the HIW to satisfy itself that continued registration is justified. It ensures compliance with: •
Care Standards Act 2000 and associated Regulations whilst taking into account the National Minimum Standards
•
The setting’s own statement of purpose
Readers must be aware that the report is intended to reflect the findings of the inspector at the particular inspection episode. Readers should not conclude that the circumstances of the service will be the same at all times; sometimes services improve and conversely sometimes they deteriorate. The National Minimum Standards are also very detailed and some are technical in nature and the HIW does not look in depth at all aspects of these standards on each visit. The report clearly indicates the requirements that have been made by HIW. This includes those made by HIW since the last inspection report which have now been met, requirements which remain outstanding and any new requirements from this recent inspection. The reader should note that requirements made in last year’s report which are not listed as outstanding have been appropriately complied with. If you have concerns about anything arising from the Inspector's findings, you may wish to discuss these with the HIW or with the registered person. The Healthcare Inspectorate Wales is required to make reports on registered facilities available to the public. The report is a public document and will be available on the National Assembly web site: http://www.hiw.org.uk/ PP/LB/02TherapyCtr/0607
3
OVERALL VIEW OF THE HEALTHCARE SETTING An inspection team of four inspected the O2 Therapy Centre’s Ltd. Policies and other documentation were examined. The chamber, treatment room and equipment was also viewed and examined. The clinic is located in a unit, on an industrial estate, in an enterprise park. Parking is available at the clinic. O2 Therapy Centres Ltd promotes and offer treatment for Acne, Sports Injuries, Healing Cosmetic\ Surgery, Health & Beauty, Fertility Spa, Psoriasis, Eczema, Whiplash, Detox, Hyperbaric Fatigue through the of provision High Dosage Oxygen Therapy (HDOT). The treatment/chamber room is clean, tidy and appropriately maintained. All procedures, records and equipment were available and in order. Patient records are kept separately and securely. Documentation and information relating to the oxygen therapy treatment is detailed and given to all patients, pre and post treatment. The manager and the HDOT (high dosage oxygen therapy) operators have attended appropriate courses and received updates on a regular basis. The Policies and procedures are time- dated. However, it was noted that some policies were due to be reviewed. This was discussed with the manager and responsible individual at the time of the inspection. A Written Notification of Action was served during the inspection, due to the absence of a fire detector within the new office area. The inspection team would like to thank the management team and staff for their time and co-operation during the announced inspection.
METHODOLOGIES USED IN THIS INSPECTION Examination of Pre-inspection information, policy and procedure documents. Discussions with the management team.
PP/LB/02TherapyCtr/0607
4
INFORMATION PROVISION Inspector’s findings: The statement of purpose and the members guide contains all required information. However, it was noted that the guide needs to be amended from CSIW to HIW. It was also noted that the policy on confidentiality needs to be expanded. The statement of purpose will be given with the member’s guide at time of consultation. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None Good practice Recommendations: It was also noted that the policy on confidentiality needs to be expanded. Reference to CSIW in documents needs to be amended to HIW
PP/LB/02TherapyCtr/0607
5
QUALITY OF TREAMENT AND CARE Inspector’s findings: Policies and procedures in place. There is a policy on access to health records. Detailed pre and post treatment information is available and given to patients. It is noted and commended the starter information pack which is given to all new patients. Treatment provided to patients is in line with appropriate guidelines with regard to hyperbaric oxygen pressures. The centre utilises a specific medical adviser as required. All patients receive questionnaires with regard to the quality of their treatment and care. Outcomes are noted and acted upon. All patients receive a questionnaire, these questionnaires will be collated on an annual basis, and outcomes will be acted upon. The manager hopes to do a pye chart in relation to questionnaire outcomes, to display within the guide. Policies and procedures in place. The majority are time-dated. However, as noted above, some policies are due for reviewing. It is advised that the confidentiality policy be expanded.
Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None Good practice Recommendations: It is advised that the confidentiality policy be expanded.
PP/LB/02TherapyCtr/0607
6
MANAGEMENT AND PERSONNEL Inspector’s findings: The manager has undertaken appropriate courses and has the qualifications and experience required for undertaking, and supervising this treatment. There is a clear line of accountability for the delivery of this treatment and service. Appropriate management structures in place. Human resources policies and procedures are in place. One member of staff is currently undergoing Criminal Records Bureau checks. Other staff members have had the appropriate CRB check. The manager supervises HDOT operators on a monthly basis. This supervision is formalised and recorded. Staff appraisal and review has been commenced. Policy and procedure available. There are protocols with reference to the cleaning of the chamber, wounds, bodily fluids and disposal of waste material. The centre does not treat children. Policy and procedure available and in place. The manager is trained to level 3 of the POVA programme. There is a staff POVA training programme at the centre. Requirements made since the last inspection report, which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: Action Required
Timescale for Regulation Number completion Staff and volunteers need to be CRB Immediate and Regulation 18 checked. ongoing. To be monitored
PP/LB/02TherapyCtr/0607
7
COMPLAINTS MANAGEMENT Inspector’s findings: Complaints policy and procedure available. The complaint’s policy and procedure clearly outlines the process for patients on how to make a complaint. The complaint’s procedure requires amending. The reference to CSIW needs to be changed to HIW. Whistle blowing policy and procedure in place. There are clear lines of management support. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None Good practice Recommendations: The complaint’s procedure requires amending. The reference to CSIW needs to be changed to HIW.
PP/LB/02TherapyCtr/0607
8
PREMISES, FACILITES AND EQUIPMENT Inspector’s findings: The premises for the HDOT treatment are safe and appropriate for that treatment. Policies and procedures are in place. Health and Safety - there is access to specialist advice. Fire drills and training are carried out. Maintenance procedures are carried out according to the programme. Equipment is maintained and serviced as required. Records available with service dates. Daily checks are also carried out on the equipment. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: Action Required
Timescale for completion Fire detector, connected to main alarm Two Weeks system needs to be installed in new office area. Thermo- regulatory valves are required Four Weeks to be fitted to washbasins in toilet areas.
PP/LB/02TherapyCtr/0607
Regulation Number Regulation 24(4)(a)
Regulatory 24(2)(d)
9
RISK MANAGEMNT Inspector’s findings: Risk management policy and procedures in place. The manager reviews risk assessment forms every six months. The centre manager is the designated lead for risk management. It is also covered in the staff induction and training programme. It was noted that the new office area needs to be incorporated into the centre’s fire risk assessment. There is a mechanism in place to deal with alert letters regarding Medical Advice Agency information and National Health Service alerts. However, as stated previously, additional managerial arrangements must be put in place, for when the manager is not available. Policy and procedures in place. There are clear protocols in place with regard to any incident regarding the chamber. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
10
RECORDS AND INFORMATION MANAGEMENT Inspector’s findings: Individual patient records are maintained and stored separately and securely. Only the relevant member of the staff has access to the key. Patients’ health history is taken during the consultation session. Records are maintained of all episodes of treatment and responses. All patients sign a detailed consent form, prior to treatment. Policy and procedures in place. The centre complies with the eight Data Protection Principles. All staff are made aware of the need for patient confidentiality. It is covered during staff induction. However, as noted previously the policy on confidentiality needs to be expanded. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None Good practice Recommendations: The policy on confidentiality needs to be expanded.
PP/LB/02TherapyCtr/0607
11
RESEARCH Inspector’s findings: No research is currently carried out at the centre. Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
12
PRESCRIBED TECHNIQUES AND TECHNOLOGIES STANDARD P7 – ARRANGEMENTS FOR HYPERBARIC OXYGEN TREATMENT IN TYPE 1, 2 AND 3 CHAMBERS Inspector’s findings: The objective of the inspection was to satisfy the Healthcare Inspectorate Wales that the chamber and all ancillary equipment needed to deliver oxygen therapy was up to the required standard, i.e to: The Code of Construction and Working Practice for Low Pressure Barochambers. Wolfson Hyperbaric Medicine Unit University of Dundee June 2003 (with permission). The inspection consisted of the following sub-sections: 1. The air system 2. The water deluge 3. The oxygen system 4. Chamber operating panel 5. The chamber (dome type) 6. General Each of which is covered in detail below. The check -list used by the inspector /adviser is included in this report. THE AIR SYSTEM Checks should be made to ensure that:
. The compressor filter pack is in date. . The compressor oil and water traps are exhausted out of the building. There is adequate ventilation for the compressor.
. There are no air leaks in the compressor area.
. The integrity and security of pipe work are sound by following the pipe track to the receiver. . The receiver test certificate is in date. The safety valve operates and that the receiver has a contents gauge and a bottom drain.
. The receiver can be isolated from the chamber by a valve.
. The integrity and security of pipe work are sound by following the pipe track to the main air filter packs.
The main air filter packs are in date. . The integrity and security of pipe work are sound by following the pipe track to the operating panel, likewise from panel to chamber hull. . The chamber exhaust pipe terminates to atmosphere outside the building.
COMMENTS ON THE AIR SYSTEM The air system was well up to standard and did not give rise to any issue of safety.
PP/LB/02TherapyCtr/0607
13
WATER DELUGE Checks should be made to ensure that: . The water receiver certificate is in date. The air supply to the water receiver is sound and can be isolated.
The water supply to the deluge receiver can be isolated from the water main.
The receiver has a contents gauge and a safety and bottom valve.
The integrity and security of pipe work is sound by following the pipe track from the water receiver to the chamber. The deluge system can be tested without flooding chamber.
COMMENTS ON THE WATER DELUGE The water deluge receiver was lagged with fibreglass insulation to prevent any possibility of the water in the receiver freezing. No issues of safety were found. OXYGEN SYSTEM If it is a cryogenic system refer to oxygen supplier. If it is a high pressure cylinder system, check that all cylinders are properly stored and securely mounted. The following checks are made to ensure that:
The cylinder connections and manifold systems can be isolated.
The gas reducing valves are securely fitted and can be isolated from the Cylinder’s and that it contains a gauge, which displays cylinder pressure, together with a gauge which displays line pressure after reduction.
The system can be isolated from the chamber.
The integrity and security of pipe work is sound by following pipe track to the chamber panel and that a gauge is incorporated in the panel that displays line pressure. The track is followed to the chamber hull. The oxygen exhaust pipe terminates to atmosphere outside the building.
COMMENTS ON THE OXYGEN SYSTEM Since the last inspection, the BOC contact number has been clearly displayed and a pair of gloves are by the unit to prevent a possible 'cold burn' in the event the unit needing to be turned off. The oxygen storage was a L200 cryogenic system from BOC, at the time of the inspection, the unit had just been serviced by BOC. No issues of safety were found.
PP/LB/02TherapyCtr/0607
14
CHAMBER OPERATING PANEL Checks should be made to ensure that:
The operating panel does not contain broken valve handles, cracked or broken gauges.
Two-way communications can be maintained with the chamber at all times.
A standard telephone is within easy reach of the operating panel.
The water deluge system can be operated and stopped from the operating panel.
The oxygen monitor is working and can be clearly seen from the operating panel.
The operating panel contains a timing device or that a clock is clearly visible.
COMMENTS ON THE OPERATING PANEL The panel was up to standard. No issues of safety were found. THE CHAMBER (dome type) The test date of the chamber is valid.
All pipe work connected to the chamber is secure and does not leak. chamber is fitted with an overpressure valve set at 2.1 A TA.
The chamber is electrically grounded.
All electrical connections to the chamber are secure and insulated.
The interior of the chamber is clean and free from rubbish or prohibited items.
The seating is firm and secure.
The oxygen pipe work connections are secure and do not leak.
The flexible pipe connectors from the masks to the oxygen supply are secure and do not leak.
The oxygen supply can be shut off from within the chamber.
Two-way communications with the operating panel can be maintained at all times.
All electrical connections are secure and insulated.
The light housings, if any, are complete and are not damaged.
PP/LB/02TherapyCtr/0607
The
15
Check that the air inlet is fitted with a silencer and that the supply can be shut off from within the chamber.
The chamber exhaust is fitted with a device that does not permit the pipe to be blocked.
The water deluge heads are clear from obstructions.
The view ports are not obstructed or damaged.
COMMENTS ON THE CHAMBER The chamber was pressurised to approximately 8ft and, while inside, each demand and dump valve was tested by breathing. All valves fitted worked properly and no sound of leaking was heard. No issues of safety were found. GENERAL
Check the housekeeping of the general chamber area.
Check that H & S E Certificates and warning notices are displayed and ensure the following documents are in place:
A general explanatory document and a safety manual is in place with emergency procedure checklists.
An overall maintenance schedule is maintained.
Examine the log detailing periodic in-service safety training for chamber staff.
Inspect records of inspection, maintenance and repair work for the chamber and ancillary equipment.
Insurance details, test certificates for all pressure vessels, receivers etc, with a displayed certificate of third party public liability.
COMMENTS ON GENERAL The chamber and general area were clean and tidy. No issues of safety were found.
Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
16
STANDARD P8 – STAFF QUALIFICATIONS AND TRAINING FOR TYPE 1 AND 2 CHAMBERS Inspector’s findings: None Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
17
STANDARD P9 – FACILITIES FOR TREATMENT IN TYPE 1 AND 2 CHAMBERS Inspector’s findings: None Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
18
STANDARD P10 – PATIENT CARE IN TYPE 1 AND 2 CHAMBERS Inspector’s findings: None applicable Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
PP/LB/02TherapyCtr/0607
19
STANDARD P11 – CRITICAL CARE IN TYPE 1 CHAMBERS Inspector’s findings: None Requirements made since the last inspection report which have been met: None Requirements which remain outstanding from previous inspection activity: None New requirements from this inspection: None
Inspectors Name: P Price Inspectors Signature:
PP/LB/02TherapyCtr/0607
Date: 15th November 2006
20
![National Assembly of Suriname [with LOGO]](https://kipdf.com/img/300x300/national-assembly-of-suriname-with-logo_5b0334298ead0e63738b45e9.jpg){kind=logo}
