Sturdee Community Hospital

The provider had addressed most of the concerns identified at the lastassessment relating to the well led key question. The exception to this was therisk register, which still needed improvement. Staff had not recorded wheneach risk had been identified. Risks that we would expect to be present werenot. The register contained many low level risks which would be better placedelsewhere. There was no provided guidance on how the grading of risks hadbeen calculated. Leaders were aware of and told us that governance was anarea which needed high focus. The registered manager was new in post,having been at the service for approximately 4 weeks. From January 2024, theservice had produced a monthly ‘lessons learnt, and actions taken’ log. Wenoted staff had taken and recorded several actions between January andMarch. Staff had failed to record actions between April and June 2024, despitethere being over 200 incidents reported. We reviewed some governancemeeting minutes. Staff had recorded actions from the meetings, but not allactions had been assigned to staff members, nor had target dates forcompletion. We also noted that during a staff meeting, an issue was raisedabout agency staff not having access to the electronic incident form, andtherefore had to rely upon regular staff to access the system to record incidentsaccurately. We were concerned that some incidents may not be recorded if staff were busy. We did not find the Freedom to speak (F2SU) arrangements inplace were effective. No concerns by staff had been raised through their F2SUprocess between January and June 2024. Yet CQC had 2 members of staffcontact us to raise concerns. A number of patients were on enhancedobservations, with lack of plan as how the patient could reduce these. We willrequire an action plan to address breaches under Regulation 17: Good Governance.