23 May 2023
During a routine inspection
We rated this location requires improvement because:
- The service did not have clear training records and managers did not use effective processes to check and record mandatory training compliance.
- Staff did not consistently complete environmental and equipment cleaning records and there were no action plans to demonstrate that managers addressed non compliance found through audit.
- Staff did not complete and update risk assessments for each woman.
- The service did not always operate effective governance processes. We found staff recruitment processes were not always followed, and managers did not check to make sure staff were aware of and understood guidance and key policies.
- Leaders and teams did not always identify relevant risks and issues and identify actions to reduce their impact.
However:
- The service had enough staff to care for women and keep them safe. Staff understood how to protect women from abuse.
- Staff worked well together for the benefit of women, supported them to make decisions about their care, and had access to good information.
- Staff treated women with compassion and kindness, respected their privacy and dignity and made it easy for people to give feedback.
We rated this service as requires improvement overall. This was because we rated safe and well-led as requires improvement and caring and responsive as good. We do not rate the effective domain in diagnostic and screening services.