3 The Beeches

This was the first inspection for this location. We rated it as requires improvement because:

• The service did not have robust governance processes that provided appropriate assurance to managers about the safety and effectiveness of the service.
• There were a number of policies awaiting review or in the process of being reviewed. These had not been updated in line with the change in service model or to reflect the current organisational structures or leadership. It was not always clear about who had certain specific responsibilities within the organisation.
• The service did not have a vision and values underlying the work being undertaken by the service and staff; that would support the consistency of responses and services being provided to patients.
• The service did not have processes for routinely gathering patient and family feedback about the service or their experiences of assessment and treatment.
• The service had not developed outcomes or key performance indicators that they routinely reviewed or reported on, although patient progress was tracked on an individual level.
• Formal supervision records were not being kept and there was no evidence as to how frequently supervision had been taking place. It was not clear how the service was supporting staff with continuous professional development.
• The service did not have appropriate first aid arrangements within the building as per the minimum requirements set out by the Health and Safety Executive in respect of first aid. The service did not have all appropriate health and safety assessments to ensure any risks associated with the building were being managed.

However:

• Patients gave positive feedback about staff and their experiences of the service. Patients felt the staff were responsive. Staff were attentive to patients and families when they contacted the service and responded to patients in a kind and pleasant manner.
• During assessments, Families were being involved in assessments and could provide their input and opinion.
• There was evidence of ongoing review of patients using monitoring tools to review the individual’s progress and development.
• The service utilised patient background and feedback as part of the assessment process; gathering information from additional sources where possible.
• The service had begun to develop clinical governance meetings which reflected the beginning of positive change regarding governance. Managers were open and honest about the limitations of the service in this area.