Birmingham

We have not previously inspected this location. We rated it as requires improvement because:

• There service did not consistently manage cleanliness, hygiene, and maintenance and the provider was slow to act on risks. While staff reported safety incidents, a lessons learned process was in its infancy and there was no well-defined track record of improvements.
• Clinical care was based on national guidance but there was limited monitoring of effectiveness, and the audit programme was not designed to drive efficacy and quality. Managers did not have assurance of consistent evidence-based care.
• Staff were trained in key skills but did not have good access to continuing professional development or specialist training.
• Governance systems were undergoing significant overhaul and improvement to address shortfalls in quality and clinical oversight and risk management. The provider had identified and was acting on key risks and changes were not yet embedded. The improvement programme aimed to address gaps in leadership, performance monitoring, and clinical quality assurance.
• Engagement between the provider and local clinic staff and patients was inconsistent. While this was an area of focus for improvement, there was not a well-defined programme to address key issues.

However:

• The service had enough staff to care for patients. Staff understood how to protect patients from abuse. They carried out good pre-operative risk assessments, kept good care records, and managed medicines well.
• Staff provided good care and treatment and managed pain relief well.
• Staff treated patients with compassion and kindness and respected their privacy and dignity. They supported patients to make decisions about care and patient feedback was generally good.