Updated 14 May 2024
We carried out an announced assessment on 29 May 2024. We found breaches of regulation from the previous inspections of January and March 2024 had not been addressed. Following this, the service is rated as inadequate overall, and for providing safe, effective and well-led services. Our key findings were: Clinical records did not meet professional standards and the electronic record keeping system did not provide sufficient oversight of patient risk. The provider did not keep up to date with best-practice guidelines, updates, or safety alerts. There were no systems and processes in place to support safe information sharing or staffing, and the provider did not articulate an understanding of the importance of this. Safeguarding policies were not sufficiently clear, and the provider did not follow the policy in place. The provider did not have adequate discussions with patients about their care and treatment options so patients were not able to make informed choices or properly consent to treatment as a result and did not follow national policies or best practice guidelines. There were no systems and processes to monitor outcomes and provide assurance that treatments were safe and effective. There were no systems or processes to support governance and leadership. There were no systems or processes in place to assure the service it was providing safe and effective care. The provider showed a lack of understanding of governance and its importance to patient safety. The provider had not responded to continued breaches of regulation found at previous inspections in order to mitigate risks to patient safety and eliminate identified breaches.