critical“The service did not offer suitable psychological therapies as part of the service user treatment in line with national guidance on best practice. This was a breach of regulation 9 (3)(b)”
safeguarding
1 finding
critical“There was no dedicated female only lounge day space that was not accessed by male patients. The female lounge was used by male patients at times. This was a breach of regulation 10(2)(a)”
governance
1 finding
moderate“a small number of audits had not been fully completed and did not always clearly record what action had been taken to show that shortfalls had been fully addressed”
record keeping
1 finding
moderate“one recent monthly audit of Mental Health Act paperwork was not completed fully as it did not check detention renewal dates fully even though there had been an incident of a lapsed detention”
consent capacity
1 finding
minor“best interest considerations for certain decisions about patients who lacked capacity were not always fully recorded on the provider's own recording systems”
staffing levels
1 finding
minor“There were two nurse vacancies (one of which was maternity leave cover) and four health care assistants.”
leadership
1 finding
minor“Some staff felt that a recently introduced rota system did not fully work to enable them to have a good work/life balance.”