23 & 24 August 2022
During an inspection looking at part of the service
Our rating of this location went down. We rated it as requires improvement because:
- There was no emergency medicines stored in the service. This did not meet the requirements of the guidance which stated they should have a minimum of adrenaline.
- Staff were not receiving autism and learning disability training which is now a requirement of the Health and Care Act 2022.
- Registered staff were not receiving immediate life support training which is a requirement of Resuscitation Council UK.
- The service had commissioned MAYBO as an accredited provider for Bild Association of Certified Training, which complies with the Restraint Reduction Network Training Standards. However, this should have been introduced in April 2021 and there was only 60% compliance at the inspection, meaning there was not enough trained staff to ensure staff could respond to incidents.
- Staff records did not meet the requirements of Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We reviewed five staff files and there were gaps in three of the records.
- There was no oversight of the induction of agency staff. There were five agency induction checklists missing for agency staff that worked in the two weeks prior to the inspection.
However:
- Staff assessed and managed risk well and followed good practice with respect to safeguarding.
- Medicines were managed safely.
- Records showed regular supervision and appraisals took place. Appraisals included the 360 feedback from patients.
- Patients spoke positively about the service, including the improvement in the food, following a new chef starting.