21 February 2023
During a routine inspection
We rated this location requires improvement because:
- The service did not have clear training records and managers did not use effective processes to check and record mandatory training compliance.
- The service did not demonstrate all staff had completed safeguarding training to a level appropriate to their role and in accordance with intercollegiate guidance.
- Substances hazardous to health subject to control of substances hazardous to health (COSHH) regulations 2002 were not always stored in accordance with the provider’s infection prevention and control policy.
- Staff did not complete and update risk assessments for each woman.
- Although the manager collected audit data of performance metrics, the service did not always record findings and action plans and use these results to understand performance, make decisions and make improvements.
- The service did not always make sure staff were competent for their roles. For example, there were no completed induction and appraisal records.
- The service did not operate effective governance processes. For example, staff recruitment processes were not always followed, audit activities were not always documented and managers did not check to make sure staff followed guidance.
However:
- The service had enough staff to care for women and keep them safe.
- The service controlled infection risk well.
- Staff worked well together for the benefit of women, supported them to make decisions about their care, and had access to good information.
- Staff treated women with compassion and kindness, respected their privacy and dignity and made it easy for people to give feedback.