3 January 2024
During an inspection looking at part of the service
Our rating of this location improved. We rated it as requires improvement because:
- Whilst the service recorded incidents, there was not a robust system for reporting and monitoring incidents. However, leaders told us they were implementing a new system imminently which would enable them to have better oversight of incidents.
- At the time of this inspection, the service still did not have robust systems for gathering patient feedback to help shape services.
- The service conducted staff surveys but there was no evidence of collating and analysing feedback in order to make improvements.
However:
- The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. During the previous inspection the safeguarding lead did not have the appropriate level of safeguarding, however there were now 2 safeguarding leads with Level 3 training.
- The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service had made improvements since the last inspection including introducing an infection prevention and control lead and regular audits. They were no longer undertaking any procedures requiring general anaesthetic which reduced risks including that posed by the location of the theatres on the first floor.
- At the time of the previous inspection, we found that leaders did not fully monitor the effectiveness of the service and there were insufficient governance processes in place. There was now a new leadership team, and a clear governance process was in the process of being embedded in the service.