16 and 17 November 2021
During an inspection looking at part of the service
Our rating of this location stayed the same. We rated it as inadequate because:
- Staff did not always understand how to protect patients from abuse. There was not a robust system and process in place for the appropriate and timely referral of safeguarding concerns.
- The service did not always control infection risk well, the premises and equipment were not always visibly clean, and some policies were still not fully reflective of the service and it was unclear what monitoring processes had been implemented. The design, maintenance and use of equipment did not always keep people safe.
- The design, maintenance and use of equipment and premises did not always keep people safe.
- There was limited assurance that there were robust systems and processes in place for the appropriate and timely referral, triage and escalation of patient care. There was limited evidence that the risk to patients and staff during care and treatment had been considered and mitigating actions identified.
- Records were not always stored securely and easily available to all staff providing care.
- The service did not always manage patient safety incidents well. Staff did not always recognise and report incidents and near misses. Managers did not always investigate incidents or shared lessons learned with the whole team and the wider service.
- There remained concerns about the competency and recruitment checks for agency staff.
- We had concerns raised with us from patients that it was not easy to contact the provider and raise complaints.
- Whilst steps had been taken to strengthen the leadership structure, leaders did not all have the skills and abilities to run the service. The service was receiving support from external agencies to fulfil leadership roles and there was not a robust process in place to ensure sustained long-term effective leadership capacity and capability to assess, monitor and improve the quality and safety of services provided.
- Leaders did not operate effective governance processes, throughout the service and so staff at all levels could not be clear about their roles and accountabilities.
- Whilst some improvements had been made to systems and processes in relation to the management of risks, issues and performance. There was not a robust system and process in place to assess and monitor the improvements that had been implemented and risk management processes were not robust.
However:
- The service provided care and treatment based on national guidance and evidence-based practice. Improvements had been made to quality assurance processes and the service had implemented an audit schedule.
- The service made sure staff were competent for their roles. Improvements had been made to the appraisal process for staff and there were plans to hold supervision meetings with them to provide support and development.
- Consent documentation for intimate ultrasound examinations had been updated to meet national guidance and the policy had been updated to reflect this.
- There was a process for people to give feedback and raise concerns about care received. The service investigated complaints and included patients. Improvements had been made to the process to evidence lessons learnt and share them with all staff.
- The service recognised that work to improve the culture in the organisation was required but had not progressed since the last inspection. Leaders we spoke with felt valued and supported in their roles.
- Some improvements had been made to policies and monitoring processes.
Following our inspection, we took enforcement action under section 29 in which we issued two warning notices, due to risks identified with safe care and treatment and good governance.