11 June and 14 June 2021
During a routine inspection
We rated this location as requires improvement because:
- Although we found the service largely performed well, it did not meet legal requirements relating to safe care and treatment, and good governance, meaning we could not give it a rating higher than requires improvement.
- Staff did not all receive the correct level of safeguarding training in order to safeguard people from the risk of abuse.
- The service did not ensure all staff completed mandatory training and that they were kept up-to-date.
- The service did not carry out quality assurance checks on equipment to ensure it was safe to use.
- The service did not have a process for assessing the quality and safety of the service.
- The service did not monitor referral rates to other healthcare providers.
- The service did not have a formalised process for recording and monitoring governance.
However:
- The service had enough staff to care for women and keep them safe. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records.
- Staff treated women 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 women, families and carers.
- The service planned care to meet the needs of local people, took account of women’s 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 their results.
- Staff felt respected, supported and valued. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities.