28 to 29 November 2023
During an inspection looking at part of the service
Our rating of the service stayed the same. We rated it as requires improvement because:
- Medicines were not always safely managed.
- Patients did not always have regular one-to-one sessions with their named nurse.
- Staff did not always assess risk well.
- Patients and some staff raised concerns about the difficulty in communication at times due to a number of staff who do not speak English as a first language.
- Information systems were not always effective due to paper based systems which staff found difficult to navigate.
- Governance processes did not always work effectively to ensure good oversight of quality and performance data and that ward procedures ran smoothly. The processes in place did not always identify gaps in recording and whether care plans, risk assessments and risk management plans were in place or up to date.
- Audits in place did not always work effectively to monitor the quality and safety of care provided or ensure improvements were made where necessary.
However:
- Staff followed good practice to safeguard patients. Staff were able to recognise and report abuse appropriately.
- Staff knew what incidents to report, how to report them and they were appropriately recorded on the patient information system.
- Staff minimised the use of restrictive practices. Staff undertook patient observations and had good knowledge of individual patient risks.
- Staff were up to date with their mandatory training.
- Staff felt as though they were respected, valued and supported.
Following this inspection, we issued the service with a warning notice served under Section 29 of the Health and Social Care Act 2008. We found that the service was failing to comply with Regulation 17 Good governance.
We found the service had failed to operate effective systems or processes to ensure the compliance with the requirements of regulation 17. We found the service was not maintaining accurate, complete or contemporaneous records. We found issues with the governance of medicines and we found environmental issues that had been identified as previous issues had not been acted on.