23 November 2021
During a routine inspection
Our rating of this service stayed the same. We rated it as required improvement because:
- The governance and leadership of the service did not fully protect the safety of the patients. There was no oversight of mandatory training compliance rates. Staff did not always have or had not completed all the relevant training. Governance meetings and supervisions were not held and safety information was not collected in order to improve the service. Policies and procedures were not evidenced as being understood by staff.
- Governance and leadership of the service did not effectively manage performance. The service did not have a system to effectively manage risks or audit the quality of the service. Data was not used to make decisions and improvements. Leadership did not use monitoring of the service to support ongoing improvements which could potentially put patients at risk of avoidable harm.
However:
- The service had enough staff to care for patients. The service-controlled infection risk well. People could access the service when they needed it.
- Staff provided good care and treatment. Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided emotional support to patients, families and carers. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.