12 and 13 July
During a routine inspection
- The service did not meet the target time of 18 weeks for seeing people from referral to assessment and assessment to treatment. The referral to assessment waiting time was 46 weeks. The waiting time for referral to treatment was 50 weeks.
- The service did not ensure that all appropriate staff received regular supervision and annual appraisals in accordance with their own policy.
- Managers did not receive sufficient up to date information to have oversight of specific performance areas.
However:
- People were protected from abuse and poor care. The service had sufficient, appropriately skilled staff to meet people’s needs and keep them safe.
- People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. People had their communication needs met and information was shared in a way that could be understood.
- People were involved in managing their own risks whenever possible. Staff developed positive behaviour support plans with people who used the service so that they were aware of any risks they posed to themselves, others or their environment.
- Staff were aware of what strategies to use to minimise and manage risks. Staff anticipated and managed risk. They had a high degree of understanding of peoples’ needs.
- People’s care, treatment and support plans, reflected their sensory, cognitive and functioning needs. People made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals.
- People who used services and those close to them were active partners in their care. We reviewed four care records and saw staff were fully committed to working in partnership with people and making this a reality for each person.
- Staff empowered people who use the service to have a voice and to realise their potential. They showed determination and creativity to overcome obstacles to delivering care.
- Patients could give feedback on the service and their treatment and staff supported them to do this. People were empowered to feedback on their care and support. We saw examples where staff had encouraged feedback using an easy read “we welcome your feedback” form. We saw evidence that staff had acted on this feedback.
- Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.
- Staff supported people through recognised models of care and treatment for people with a learning disability or autistic people. Leadership was good, and governance processes helped the service to keep people safe, protect their human rights and provide good care, support and treatment.
- Staff worked with social care providers to ensure care was line with best practice and national guidance. For example, quality standard 101, behaviour that challenges National Institute for Heath and Care Excellence (NICE).