14 to 15 September 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 women and keep them safe. Staff had training in key skills and understood how to protect women from abuse. Incidents were reported, investigated and shared 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 women safe from avoidable harm.
- The service provided care and treatment based on national guidance and evidence-based practice and monitored some effectiveness of care and treatment delivered. Staff worked well together for the benefit of the women.
- The service had a strong, visible person-centred culture. Staff were highly motivated and passionate. Women were treated with compassion and kindness and staff respected their privacy and dignity.
- There was no waiting list at the time of inspection and women told us they were able to access the service easily.
However:
- Some governance processes were not embedded such as the oversight of staff records, and the development of service risk registers.
- The provider did not collate or review data regarding booking numbers or women who were referred directly into the NHS central system.
- The provider did not have a formal system in which feedback could be collated, monitored or reviewed.