10 February 2023
During a routine inspection
We had not previously inspected this service. We rated it as inadequate because:
- The service did not provide or monitor mandatory training. Facilities were not designed to meet the needs of all women. Equipment was not always used appropriately to keep women safe. Staffing was not always enough to meet the needs of women. Care records were not detailed. Staff did not assess risk to women including infection risk was not always controlled well. The service did not have processes in place to identify and record incidents.
- The service did not provide good care and treatment. Managers did not monitor the effectiveness of the service or make sure that staff were competent.
- The service did not always take account of individual needs.
- The service did not meet the needs of all people because of the location. The service did not make it easy for people to follow a complaints process.
- Managers did not run services well because detailed policies were not available and there were no systems for outcome monitoring.
However:
- Staff knew what to do in an emergency.
- Staff worked well together for the benefit of women, explained information clearly and provided information through the website on how to lead healthier lives.
- Staff treated women with compassion and kindness and respected their privacy and dignity.
- The service offered appointments at times to suit women. They made it easy for people to book appointments at short notice.
- The service received positive feedback from those who used it.
Following this inspection we served the provider a Warning Notice under Section 29 of the Health and Social Care Act 2008. The warning notice told the provider they were in breach of Regulations 12 and 17 and gave the provider a timescale to make improvements to achieve compliance. The principles we use when rating providers requires CQC to reflect enforcement action in our ratings. The warning notice identified concerns in the safe and well-led domain. This means that the warning notice we served has limited the rating for safe and well-led to inadequate.