01 February 2024
During a routine inspection
Our rating of this location stayed the same. We rated it as inadequate because:
- The premises and equipment were not safely managed and presented a number of infection risks. Processes and systems to manage infection control risks were not fit for purpose. Staff and leaders did not understand the principles of infection control.
- Medicines management processes did not meet national standards and presented a significant risk to patients.
- The provider had improved some aspects of fire safety in the previous 5 months but practices still did not meet safe standards.
- The service did not ensure the privacy and dignity of patients and information management processes for the use of CCTV were not fit for purpose.
- There was limited evidence of evidence-based practice. The provider did not use established systems and frameworks to benchmark, audit, or monitor clinical activities and patient outcomes.
- The provider did not have a coherent clinical governance framework, the leadership structure was vague, and senior staff had a fundamental lack of understanding of risk. Risks we had previously told the provider to address remained because there was a lack of competence and understanding in the provider about recognising and responding to risks.
However:
- Patients reported high levels of satisfaction with the service.
- The provider had introduced new policies and standard operating procedures.
- Staff provided consistent follow-up care after treatment and worked with patients to meet their expectations.