23 - 24 November 2021
During a routine inspection
Our rating of this location stayed the same. We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service mostly controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
- Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
- 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, took account of patients’ 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 treatment.
- Leaders ran services 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 patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
However:
- Compliance with two key mandatory training modules was low and did not meet the service target. Hand hygiene audits were not completed in a timely way in line with the service policy. We saw one box of out of date gloves stored in the surgical department. Records in surgery were not always stored securely in the surgical department. Staff in outpatients did not always wear gloves correctly for infection prevention control. Three-point patient ID checking was not consistently in place for patient identification in outpatients.
- Complaint responses did not always meet the service target and we did not see information displayed in the department to support patients to make a complaint if they needed to.
- The mechanism for monitoring actions plans and timely responses was not robust. The service did not always record identified actions to reduce the impact of identified risks and issues.