We rated the service as requires improvement because:

• The provider’s approach to improve the quality of its services was not effective or embedded throughout the organisation.
• The provider was not recording or managing risks effectively.
• Staff adherence to hand hygiene and effective cleaning procedures was poor.

• Medicines were not stored safely or securely and storage records were incorrect. However, staff prescribed and gave medicines safely.

• Staff did not use validated pain assessment tools.
• The provider did not routinely collect patient outcome data for all patients so their sample size was too small to give useful results.

• The three leaders of the organisation did not receive a formal appraisal and the board did not have sufficient oversight of safety issues.
• The provider had new systems for identifying risks that were yet to be embedded.
• Action plans were not clearly documented or followed up to gauge improvement.

However:

• The provider worked well with other agencies to protect patients from avoidable harm.

• Staff kept detailed records of patients’ care and treatment and always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe and to provide the right care and treatment.
• Staff worked together as a team to benefit patients. Doctors, physiotherapists and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion and provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.

• The provider planned and provided services in a way that met the needs of local people.

• The provider treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff.
• Managers at all levels had the right skills and abilities to run a service providing high-quality sustainable care.
• The provider engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Following this inspection, we issued the provider with a requirement notice for breaches of regulations. We told the provider that it must provide us with an action plan setting out how it will comply with the regulations.

We informed the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Details are at the end of the report.