During an assessment of Outpatients
The service was last inspected in 2014 under an old methodology and met the standards but was not rated. We carried out a comprehensive inspection of this service on 3 and 16 of December 2025 under a new methodology and rated the service as Requires Improvement. We inspected the assessment service group (ASG) outpatients.
We rated the service as Requires Improvement. We found 4 breaches of the regulations in relation to, Safe Care and Treatment, Premises and Equipment, Good Governance and Fit and Proper Persons Employed.
Not all staff had received mandatory training, and mandatory training was not assessed for different roles, meaning we were not assured all staff had received training to ensure they were competent for the roles they undertook. Not all staff had completed safeguarding training and there was no assessment of roles and responsibilities to ensure staff accessed safeguarding training at a level relevant to their role. Staff files did not include requirements to comply with schedule 3 of the Health and Social Care Act, including having a full employment history, references from previous employers and a disclosure and barring service (DBS) check. Therefore, there was no evidence only suitable staff were employed by the service. Hand washing facilities were not always available increasing the risk of spreading bacteria and viruses. Leaders did not have full oversight of the risks to the service and did not take action to mitigate risks and make improvements.
However, staff demonstrated kindness and compassion, patients felt respected and cared for. They were involved in decisions about their care and were able to make informed decisions. There was a positive culture of learning from incidents.
We requested an action plan following publication of the final report.