15 December 2021
During an inspection looking at part of the service
This was a short- notice announced focused, follow up inspection. This meant the provider had limited notice that we were inspecting. Following our previous inspection in September 2021, we took action to suspend the service from providing regulated activity. This inspection was undertaken to check the service had made sufficient improvements to allow the provision of regulated activities to resume.
Due to the focused nature of this inspection we did not rate the service and the ratings from our previous inspection remained unchanged.
This inspection found the provider had made sufficient improvement in quality and safety, which meant we did not take further action to extend the provider’s suspension.
This was because:
- Staff understood how to protect patients from abuse. Most staff had completed training on how to recognise and report abuse and they were clear how to apply it.
- The maintenance and use of facilities, equipment and premises mostly kept people safe.
- We found evidence of how staff identified and quickly acted upon patients at risk of deterioration.
- There was a new process in place to ensure records were managed and stored securely.
- The service had improved processes to make sure staff were competent for their roles, although further improvements were required.
However:
- The service did not provide mandatory training in key skills to all staff. Although there was now a system in place to make sure everyone completed it, it was not robust.
- The service did not always control infection risk well.
- There was not a robust system in place to ensure patients were supported to make informed decisions about their care and treatment.
- Not all leaders understood the responsibilities and obligations they had as the provider to meet the standards required by the regulations.
- Leaders did not always operate effective governance processes throughout the service, although there were some improved governance processes in place.