28 April 2021 and 30 April 2021
During an inspection looking at part of the service
We rated this location as Requires Improvement because:
- The service did not always provide mandatory training in key skills to staff or made sure that all staff completed it. Staff did not have the required level of training to enable them to always recognise and report abuse. Policies to keep people safe lacked detail and were not clear. The service did not always control infection risk well or use sufficient control measures to protect women, themselves, and others from infection. They did not use systems or processes to manage or store medicines. Managers did not always investigate incidents or share lessons learned.
- Managers did not always monitor the effectiveness of care and treatment to make improvements and achieved good outcomes for women. They did not always make sure staff were competent as staff records revealed gaps in pre-recruitment checks.
- The service was not always inclusive and did not always take into account women's individual needs. For example, it did not identify, meet, or support the information and communication needs for women with a learning disability, impairment, or sensory loss.
- Managers did not always understand and manage the information available to them to support improvements. They did not operate effective governance processes or have systems to manage performance effectively to enable them to make decisions and improvements. They did not always discuss shared learning from audits or incidents. The service did not always engage well with women to plan and manage services.
However:
- The service had enough staff to care for women and keep them safe. Staff assessed risks to women, acted on them and kept good care records. Staff collected safety information.
- Staff provided good care and treatment. They worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
- Staff treated women with compassion and kindness, respected their privacy and dignity, and helped them understand their conditions. They provided emotional support to women and those that accompanied them.
- The service planned care to meet the needs of local people and made it easy for them to give feedback. People could access the service when they needed it and did not have to wait too long for their results.
- Staff felt supported to develop their skills. Staff felt respected, supported, and valued. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. Staff were committed to improving services.