This is the first time we have inspected and rated this service. We rated it as requires improvement because:
- Diagnostic team meeting minutes were not consistently recorded, and it was not always clear what was discussed.
- Not all policies were in date at the time of the inspection.
- Staff had received safeguarding training however; this was not to the correct level in line with national guidance.
- The service did not have paediatric trained staff to care for children and young people and keep them safe.
- The service did not take into account the individual needs of children and young people.
- The service did not have a formal written criteria by which they assessed and accepted children and young people into the service.
- The service did not have formal processes and policies in place to reflect caring for children and young people and reference national guidance.
- The service had enough staff to care for adult patients and keep them safe. The service-controlled infection risk well. Staff carried out risk assessments for patients and kept good care records. The service managed safety incidents well and learned lessons from them.
- Staff provided good care and treatment and managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. 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 and did not have to wait too long for treatment.
- Leaders ran adult services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.
The rating of this location does not follow the CQC aggregation rules to rate. As children and young people made up less than 0.5% of total appointments, we have overruled the aggregation rules.
Following the inspection, we sent the provider a letter of intent following concerns identified in the children’s and young people service. The provider responded with an action plan by the deadline set outlining actions they would take to improve the service.