16, 17, 18 August 2023
During an inspection looking at part of the service
Our rating of this service went down. We rated it as requires improvement because:
- While staff assessed and managed risk once patients were on their caseload, the system was inconsistent and lacked standardised risk assessment tools.
- Staff mostly followed good practice with respect to safeguarding but there were inconsistencies and areas for improvement that senior leaders and governance systems had not identified.
- The provider did not have sufficient oversight of the risks relating to clinicians providing remote care, including the availability of on-demand emergency support and assurance of confidential working environments.
- Medicines management systems did not include sufficient prescription tracking capabilities to provide assurance of security and there was no audit system in place to manage risk.
- Governance systems, including for incident reporting and management, had not kept pace with the growth of the service. This meant there were gaps in assurance of risk management and the capacity of the senior leadership team to safely manage the service.
- There was a lack of evidence the provider acted on feedback from staff in the annual survey to improve working practices and address concerns.
However:
- The service provided safe care once patients were assessed and in a treatment plan.
- Staff worked well with multidisciplinary organisations to coordinate care for patients living with comorbidities and complex needs.
- Staff described good working relationships and on-demand support in a positive, collaborative culture.