Updated 31 July 2024
Date of assessment: 13 Aug 04 Sept 2024. Our onsite visit took place 13 Aug 2024. We assessed the nursing unit and there were 33 people living there. Some elements of the service had improved following our previous assessment, however, the service remained in breach of regulations. There were continued concerns around safe care and treatment, safeguarding, person centred care and governance. We looked at quality statements within the key questions of Safe, Effective, Caring and Well led. This assessment was undertaken, in part, due to an incident, following which a person using the service died. This assessment did not examine the circumstances of the incident as it is subject to further investigation. Details of the incident indicated potential concerns about the management of falls, so this assessment examined those risks for other people. Risks to people were not always fully assessed or managed. Staff and managers did not always understand their responsibilities related to safeguarding and had not always submitted statutory notifications to CQC regarding allegations of abuse. Staff did not always respond to peoples calls for assistance in a timely manner. Since the previous assessment improvements had been made in relation to incident reporting and medicines management to ensure safe practice. Some leadership and governance measures remained ineffective in identifying shortfalls and failed to assess, monitor and mitigate some risks relating to people’s health, safety and welfare. Several changes had been made to the leadership team and a recently appointed manager was working to make further improvements. Although the leadership team were working to improve the culture and listen to staff concerns, some staff indicated that they continued to not always feel safe to speak up. You can find more details of our concerns in the Safe, Effective, Caring and Well led findings below.