Updated 28 February 2024
Date of assessment: 1 to 3 May 2024. This assessment was to follow up on concerns and breaches of regulation following our previous inspection in September 2023. We assessed 17 quality statements across the safe, effective and well-led key questions. We have scored each of these quality statements and the service is rated as good overall, but we identified a breach of regulation and we rated well-led as requires improvement. Some of the services provided are not regulated by the CQC so we did not look at them. We found that significant improvements had now been made in relation to managing patient safety since the last inspection. Medicines and infection prevention and control were managed in a safe way, although we found that the storage of emergency medicines could be improved. Systems to manage risk, staffing levels and safeguarding were effective. Patient needs were assessed and evidence-based care was being delivered, with outcomes being monitored. However, whilst we found that areas of well-led were effective, some areas of governance required improvement. Clinical oversight was not led effectively and therefore some audits were not fit for purpose and audit was minimal to identify if national guidance was being met. We found one breach of regulation in relation to regulation 17.