01 November 2022
During a routine inspection
The service had enough staff with the right skills to carry out activities relevant to this service to keep people safe. Staff had training in key skills, understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records.
The registered manager monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to information when this was required.
Staff treated women with compassion and kindness, respected their privacy and dignity, and helped them understand their keepsake images. They provided emotional support to women, families and carers when this was necessary.
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 images.
The registered manager ran the service 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 women using the service. Staff were clear about their roles and accountabilities. All staff were committed to continually improving the service.
However:
- The service had not yet included training awareness for Learning Disability and Autism which had become mandatory on the 1 July 2022.
- The service had sensitive information recorded on paper which although shredded was not disposed of correctly using a confidential waste disposal service.
- The service did not have evidence of maintaining hand hygiene measures.
- Two references had not been obtained for new employees or risk assessed before starting employment.