17 November 2022
During a routine inspection
This service was previously inspected but not rated. We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
- Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
However:
- Parts of the service was often reliant on agency staff to ensure safe staffing numbers were met. Paperwork was not always completed in full, before being signed by staff.
- Policies were printed and put in folders that were not updated as the polices were reviewed. Not all staff were clear about their responsibilities under the Mental Capacity Act, despite having training in this.
- The provider was not able to show that it had taken references for all the staff and doctors on practicing privileges it employed.
- Risks on the risk register were not managed promptly and staff we spoke with did not have a common understanding of the risks they faced.