We carried out an announced comprehensive inspection on 25 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 not 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 care 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 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.

Our key findings were:

• The service had systems in place to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
• The service had systems to safeguard children and vulnerable adults from abuse.
• The service had some arrangements to ensure that facilities were safe. However, some of the information required for this was not in place at the time of inspection. For example, some service contracts and maintenance schedules were observed however, this did not cover all the equipment currently in use.
• The provider carried out recruitment checks, including checks of professional registration where relevant, on recruitment and on an ongoing basis. Policies were in place to support this. However, we found that Disclosure and Barring Service (DBS) checks were not undertaken as required for all staff members prior to employment and there was no risk assessment in place to support this.
• The service had some systems for ongoing review and improvements. This included data collection and regular monitoring of key performance indicators.
• Staff treated patients with compassion, kindness, dignity and respect.
• There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.
• The service sought feedback from patients.

We identified regulations that were not being met and the provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

• Ensure all premises and equipment used by the service provider is fit for use.

Full details of the regulations not being met are at the end of this report.

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

• Review the service infection control policy, in particular to ensure that information includes the requirements necessary to undertake scans for patients with suspected or confirmed contagious and communicable diseases and/or suppressed immune systems. The policy should also refer to the procedure for the decontamination of equipment and environment following use by patients with suspected or confirmed contagious or communicable diseases.

• Review the service protocols to ensure recommendations made following audit is actioned and the issues identified re audited to improve the quality.

• Review the records kept to demonstrate competency training for each staff member.