22 February 2022
During a routine inspection
The service had not been inspected previously.
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 and understood how to protect patients from abuse. The service controlled infection risk well and understood and reported incidents appropriately. The service-controlled infection risk well and they kept equipment and the premises visibly clean. The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm.
- The service provided care and treatment based on national guidance and evidence-based practice and monitored the effectiveness of care and treatment. Staff worked well together for the benefit of the patients. The service made sure patients had enough information to make decisions about their care.
- The service had a strong, visible person-centred culture. Staff were highly motivated and passionate. Patients were treated with compassion and kindness and staff respected their privacy and dignity.
- The service planned and provided care in a way that met the needs of local people and people could access the service when they needed it. It was easy for people to give feedback and raise concerns about care received.
- Leaders had the skills and abilities to run the service. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
However:
- Some governance processes were not embedded such as the monitoring of staff records and the development of service risk registers and incident investigations.
- The provider did not collate or review data regarding patient referral numbers and timescales in which patients were seen this meant there was no formal process to ensure patients were seen in a timely way.