21 November 2017
During a routine inspection
The service had a registered manager, which is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Safeguarding adults from abuse procedures were in place and healthcare assistants (HCAs) understood how to safeguard patients they supported. HCAs had received safeguarding adults training and were able to explain the possible signs of abuse as well as the correct procedure to follow if they had concerns.
Premises and equipment were clean and properly maintained. There were procedures in place to safely administer medicines to people.
Staff demonstrated knowledge of their responsibilities under the Mental Capacity Act 2005. Consent forms were signed by patients prior to them receiving treatment.
Patients told us they were involved in decisions about their care and how their needs were met.
Recruitment procedures ensured that only staff who were suitable, worked within the service. Disclosure and Barring Service checks had taken place, but these had taken place approximately one year after staff had already begun working at the service. There was an induction programme for new staff, which prepared them for their role.
Patients told us they were satisfied with the level of care given by staff. They said they were given helpful and accurate explanations about the treatment and that staff listened to them.
There was a suitable procedure for the investigation and resolution of complaints.
The provider’s governance framework ensured responsibilities were clear and quality performance, risks and regulatory requirements were understood and effectively managed. The provider monitored areas of their work to help them improve and learn. This included asking for the views of patients and staff.
During this inspection we found a breach of regulations in relation to the employment of fit and proper persons. We also made a recommendation about developing supervision and appraisal records. You can see what action we told the provider to take at the back of the full version of the report.