We carried out an announced comprehensive inspection on 19 September 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The service has a registered manager. A registered manager is a person who is 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.

As part of our inspection we asked for CQC comment cards to be completed by patients prior to our inspection. We received nine comment cards which were all positive about the standard of care received at the service.

Our key findings were:

• Policies and procedures were in place to support the delivery of safe care.
• The provider had a clear vision to deliver high quality care for patients.
• There were systems and processes in place for reporting and recording significant events and sharing lessons to make sure action could be taken to improve safety in the service.
• The service had clearly defined systems, processes and practices to minimise risks to patient safety; however, on the day of the inspection some of the processes had not been fully put into place. After the inspection we were provided with evidence to show that some of these processes had been implemented.
• The service had adequate arrangements to respond to emergencies.
• Staff were aware of and used current evidence based guidance relevant to their area of expertise to provide effective care.
• Staff had the skills and knowledge to deliver effective care and treatment.
• There was an effective system in place for obtaining patients’ consent.
• The service had systems and processes in place to ensure that patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• The service had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management.
• The provider was aware of and complied with the requirements of the duty of candour.
• Staff had received role specific training. However, the service had not implemented all of the required training for staff.

There were areas where the provider could make improvements and should:

• Review systems for undertaking quality improvement for patients.
• Introduce a comprehensive system of infection prevention and control practices to ensure practices are fully embedded.
• Introduce an effective system to ensure prescription security.
• Develop a system to check patients’ age and identity upon presentation.
• Maintain a comprehensive list of the required staff training.