04 and 08 August 2022
During a routine inspection
This was the first time we had inspected this service. We rated it good because:
- There was enough staff. The service was visibly clean, well maintained and controlled infection risks well. Processes were in place to manage safety.
- Staff gave service users food, fluids and pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent.
- Staff treated service users with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
- The service took account of service users individual needs 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 treatment.
- The management team were visible and approachable, there was a positive culture and staff were clear about their roles and accountabilities. The service engaged well with service users and all staff were committed to improving services continually.
However,
- Not all staff had all the required mandatory training at the appropriate level, the area adjacent to the reception was potentially unsafe and there were limited documented clinical guidelines or procedures.
- Some governance and risk management processes were in place, but more work was needed to ensure the management team had robust oversight and assurance.