Updated 5 July 2024
Date of assessment: site visit commenced on the 12 July 2024 and the off site assessment ended on the 22 July 2024. We assessed the quality statements in the safe, effective and well-led key questions. The scores for these areas have been reviewed and for safe and well-led are requires improvement and for effective is good. The service was managed by a registered manager and a management team. Quality assurance systems were not always identifying shortfalls found during our visit. Improvements were needed to the storage, administering and recording of medicines. For example, people’s thickener medicines were not always stored safely. Risk assessments for people who had vulnerable skin needed to be improved as well as care plans with repositioning information. Medicines administration charts, fluid charts and repositioning charts were not always accurate and up to date. Mental Capacity Assessment and best interest assessments were needed where people had acoustic monitoring in place. People’s personal evacuation plans did not contain important information such as the person’s mobility and equipment needs. During our assessment the registered manager took action to address most of these shortfalls although the provider’s auditing system had not identified these. People were encouraged by staff to maintain their independence and choice. Staff received training, although not all staff were able to demonstrate they had a good understanding of training undertaken. The registered manager held open sessions so staff, people and relatives could raise any concerns with them. Staff meetings were an opportunity to discuss any learning and to share important updates. The registered manager made safeguarding referrals when required and any learning was shared with staff as needed. Staff received whistle-blowing training and updates if required. The service worked in partnership with health and social care professionals so good outcomes for people were achieved.