29-30 March 2017
During a routine inspection
We do not rate sole practitioners.
We found the following areas of concern:
- The service did not have an embedded process to assess and record risks when patients were assessed at the service.
- Incidents were not being categorised and robust incident investigations were not taking place.
- There was no evidence that learning had taken place in response to serious incidents.
- The service did not always consult the patient’s GP before prescribing medication.
- The service did not distinguish between serious and less serious incidents in the reporting of incidents onto its risk register.
- Safeguarding concerns and alerts were not being referred to the local authority.
- The service did not keep minutes of the consultant psychiatrist’s supervision.
- The service did not integrate assessments into patient’s care plans where appropriate.
- The service did not monitor the patients who self-discharged from the service without a discharge plan in place.
However:
- The service was delivered in a clean and comfortable environment which was accessible and welcoming.
- The service was well staffed and responded to patient needs in a prompt and flexible manner.
- The staff understood the duty of candour and gave examples of applying this duty.
- The service had a clear care pathway. The service was able to offer patients emergency appointments within a few days. There was no waiting list.
- Patients who used the service provided very positive feedback.