14 September 2021
During a routine inspection
We rated this service as requires improvement because:
Although we found the service largely performed well, it did not meet legal requirements relating to governance, safe care and treatment and fit and proper persons: directors, meaning we could not give it a rating higher than requires improvement.
Staff did not always receive the appropriate training on how to safeguard patients in line with best practice.
The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
Staff did not always record detailed discussions of the consent process.
Managers did not always assess the effectiveness of the service, staff compliance of adhering to policies was not audited and actions were not always taken from audits to improve outcomes for patients.
Leaders did not always identify relevant risks and issues and therefore could not take action to reduce their impact.
The service did not display complaint information making it difficult for patients to share negative feedback.
The service did not have a robust process to ensure equipment was properly maintained. The design of rooms used to deliver bad news had not been considered.
However:
The service had enough staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Staff assessed risks to patients and acted on them. The service controlled infection risk well. Safety incidents were managed well and learned lessons from them.
The service provided mandatory training in key skills to all staff and had processes in place to make sure everyone completed it.
Staff provided good care and treatment and gave patients pain relief when they needed it. Managers made sure staff were competent and had access to good information.
Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care.
Staff treated patients 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 patients, families and carers.
The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
Staff understood the service’s vision and values, and how to apply them in their work.
Staff felt respected, supported and valued. Staff were clear about their roles and accountabilities and were focused on the needs of patients receiving care.