27 October 2021
During a routine inspection
Our rating of this location stayed the same. We rated it as good because:
- The service provided safe care. The premises where clients were seen were safe and generally clean. The service had enough staff although did have staffing pressures. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
- Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice.
- The teams included or had access to the full range of specialists required to meet the needs of clients under their care. Managers ensured that these staff received training and appraisal. Staff worked well together as a multidisciplinary team and relevant services outside the organisation.
- Staff treated clients with compassion and kindness, and understood the individual needs of clients. They actively involved clients in decisions and care planning. Client feedback about the service was positive and they felt involved in their care and treatment. Managers and staff were willing to go above and beyond to provide care and support.
- The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
- The service was well led, and the governance processes ensured that its procedures ran smoothly.
However:
- The ligature risk assessment did not have a clear review date or audit trail. Managers could not be assured that this had been appropriately reviewed or that it included all current environmental risks.
- There were issues with the environment such as water damage and damp in areas of the building. The provider was aware of these issues and was taking action with the landlord to address them.
- The first aid kits included items that had expired and not been removed or replaced.
- Supervision compliance rates for the provider’s targets were low for the 12 months prior to the inspection, although the provider had an action plan in place to address this and the compliance rate was improving.