The Rostra Clinic

We rated this location requires improvement because:

• Staff completed and updated risk assessments for each service user. However, baseline observations were not routinely monitored to identify potential deterioration.
• The service level agreement (SLA) with the referring National Health Service (NHS) Trust had not been reviewed to demonstrate robust governance agreement and oversight of the service.
• The service did not operate effective governance processes. For example, audit practice was not always undertaken to review potential trends and create improvement opportunities.
• Policies had not consistently been revised to reflect guidance changes and polices were not always version controlled.
• The service did not instigate regular clinical governance meetings with the referring NHS trust to evidence robust oversight of both parties.
• Local rules for the safe use of the diode laser had not been reviewed and updated.

However:

• The service had enough staff to care for service users and keep them safe. Staff had training in key skills, understood how to protect service users from abuse, and managed safety well. The service-controlled infection risk well. Staff kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment and gave service users pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of service users, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated service users with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to service users, families and carers.
• The service planned care to meet the needs of local people, took account of service users individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.