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Bromsgrove

Type Independent Healthcare Org Region West Midlands Last inspected 2 May 2023

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 5 must-do 3 should-do

Must-do actions (5)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 5
Must do
Safe
The service must ensure all staff receive mandatory training including safeguarding, the Mental Capacity Act and mandatory training on Learning Disability and Autism.(Regulation18(2)).
Regulation: Regulation 18(2)
⚠ Not all staff had completed mandatory training to keep patients safe. Not all staff received mandatory training. The service was not aware of their legal responsibility to provide training on mandatory training on Learning Disability and Autism in line with the Oliver McGowan mandatory training laws since 2022. Not all …
Must-do action 2 of 5
Must do
Safe
The service must ensure staff receive a Disclosure and Barring Service check before staff are employed in line with providers own policies and processes.(Regulation19(1)and(2)).
Regulation: Regulation 19(1) and (2)
⚠ A staff member employed to support vulnerable patients had not received a Disclosure and Barring Services (DBS) check. Some staff members had not had a DBS check to ensure they were safe to work with patients. Managers did not demonstrate oversight of this concern when we raised it.
Must-do action 3 of 5
Must do
Well-led
The service must ensure they are able to access staff records to assure themselves staff are competent and are recruited in line with regulations.(Regulation17(1)and(2d)).
Regulation: Regulation 17(1) and (2d)
⚠ Managers did not provide staff appraisals or have oversight of staff personnel files; therefore, were unable to review or update staff competency. We were unable to access staff personnel files to identify if staff did have appropriate skills, experience, and qualifications to undertake their roles when they were recruited. Managers …
Must-do action 4 of 5
Must do
Effective
The service must ensure they undertake annual appraisals with staff to ensure continuous professional development.(Regulation18(2)).
Regulation: Regulation 18(2)
⚠ Managers did not provide staff appraisals or have oversight of staff personnel files; therefore, were unable to review or update staff competency. We saw no yearly appraisals completed with staff.
Must-do action 5 of 5
Must do
Well-led
The service must develop systems and processes to identify clinical risks to the service and develop effective action plans to mitigate these risks.(Regulation17(1)and(2)
Regulation: Regulation 17(1) and (2)
⚠ Managers did not have effective systems in place to identify risks, such as inconsistencies in completing hand hygiene audits and gaps in meetings for shared learning. The overall governance and risk management of the service required improvement. No clinical risks were identified. Not all risks were assessed and managed.

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3
Should do
Safe
The service should ensure staff have access to the local authority safeguarding information.(Regulation13).
Regulation: Regulation 13
Should-do action 2 of 3
Should do
Well-led
The service should ensure staff meeting minutes have sufficient detail for staff who do not attend the meeting to understand what is discussed.(Regulation18).
Regulation: Regulation 18
Should-do action 3 of 3
Should do
Safe
The service should ensure all hand hygiene audits are maintained.(Regulation17).
Regulation: Regulation 17

Location details

CQC ID: 1-11004426498
Local authority: Worcestershire
Region: West Midlands

Inspection report

Type: Comprehensive inspection
Date: 2 May 2023
Rating: Requires Improvement
Actions: 5 must-do 3 should-do
AI-extracted 17 Feb 2026