02 March 2022
During a routine inspection
We rated this service as requires improvement because:
- The service did not meet legal requirements ensuring staff employed had the necessary checks in place, ensuring records required by risk assessments were kept, ensuring clinical waste was securely stored and using audits to ensure the quality of the service. Not all staff had training in key skills.
- Staff did not monitor the effectiveness of care by auditing their service. They were therefore unaware of how well the service was performing or if improvements were needed.
- The service had minimal systems in place to identify risk, plan to eliminate or reduce them.
- Four requirement notices were served to address the above rating for safe and well led therefore the ratings were limited to requires improvement
However,
- The service had enough staff to care for women and keep them safe. Staff understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records.
- Staff provided good care and treatment. Staff 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, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
- The service planned care to meet the needs of local people and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for their results.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services and all staff were committed to improving services continually.