The Care Quality Commission
  • Ambulance service

LSA House

Overall: Good read more about inspection ratings

Unit 2b, Lower Mount Farm, Long Lane, Cookham, Maidenhead, SL6 9EE 0333 939 8755

Provided and run by:
LSA Secure Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

12 July 2022

During a routine inspection

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. The service controlled infection risk well. The service managed safety incidents well and learned lessons from them.
  • Staff assessed patients’ food and drink requirements. The service met agreed response times. Managers made sure staff were competent.
  • Staff treated patients with compassion and kindness and respected their privacy and dignity. They provided emotional support to patients, families and carers.
  • The service made it easy for people to give feedback. People could access the service when they needed it. The service planned care to meet the needs of local people.
  • Staff understood the service’s vision and values. Staff felt respected, supported and valued. The service engaged well with patients and the community to plan and manage services.

However

  • Staff assessed physical risks to patients, but did not document mitigations, actions or the impact of those risks. This was identified at the previous inspection.
  • The adult safeguarding policy was unclear, inaccurate and contradictory and there was no contraband policy to support staff who were required to search patients for smuggled goods.
  • Managers did not monitor the number of staff days off, to ensure that there was adequate weekly rest periods and were unsure of official processes for notifying CQC of notifiable safeguarding concerns.

20 September 2021

During a routine inspection

We are placing the service into special measures. This is because the service was rated as inadequate.


Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated the service as inadequate because:

  • The governance and leadership of the service did not fully protect the safety of the patients. Staff did not always fully complete patient risk assessments and patient risk assessments did not consider physical health needs. Staff did not develop plans to follow to promote the safety of patients and reduce risk of avoidable harm. There was no process to confirm who was responsible for the safe management of patients when they were accompanied by members of staff from the booking hospital. Safeguarding of patients from abuse and improper treatment was not fully assured. Guidance for staff was not clear, policies and procedures did not always relate to the service provided and did not always include current national guidance.
  • Governance and leadership of the service did not effectively manage performance. The leadership did not use monitoring of the service to support ongoing improvements which could potentially put patients at risk of avoidable harm. The service did not have a system to effectively manage risks or audit the quality of the service. Data was not used to make decisions and improvements.

However:

  • The service had enough staff to care for patients. The service controlled infection risk well. People could access the service when they needed it. The service had some processes to engage with patients and clients who booked transport with them.
  • Staff treated most patients with compassion and kindness and respected their dignity. They provided emotional support to patients.

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

17 February 2021

During a routine inspection

Following the inspection, in response to the concerns we have described in the report of the inspection, we carried out enforcement action and imposed conditions on the registration of the provider. The conditions require the provider to report to CQC every month about the essential improvements the service has carried out to promote the safety of patients and improve the leadership of the service.

We rated the service as inadequate because:

The governance and leadership of the service did not fully protect the safety of patients. The service did not control all areas of infection risk well. Staff did not always complete patient risk assessments. Patient safety incidents were not managed well and the use of restraint on patients was not considered as an incident. The service did not ensure all restraint equipment was safe to use. Safeguarding of patients from abuse and improper treatment was not fully assured. Guidance for staff was not clear, policies and procedures did not always relate to the service provided. Staff did not fully understand their role in supporting patients who lacked mental capacity to make decisions.

The governance and leadership of the service did not effectively manage performance, nor did it use monitoring of the service to support ongoing improvements, which could potentially put patients at risk of avoidable harm. There were no processes to get feedback from organisations who used the service and there were limited processes for people to give feedback and raise concerns about care. The service did not have a system to effectively manage risks or audit the quality of the service. Data was not used to understand performance and to make decisions and improvements. The service did not have structured meetings to ensure performance was reviewed.

However:

The service had enough staff to care for patients. People could access the service when they needed it. Staff felt respected and valued. They demonstrated understanding about discrimination that mental health patients may experience.