Updated 29 August 2024
Date of assessment: 24 September to 07 October 2024. We found the service had improved since our last inspection and is now rated requires improvement. However, further improvements were needed and the service remains in breach of one legal regulation relating to governance. Whilst the provider had introduced a system to monitor, assess and drive improvement in the quality and safety of the service, this had not been fully effective at rectifying all shortfalls. We found there had been undue delay in managing some safety concerns including in relation to the environment and safeguarding, which had placed the people who used the service at risk. The provider had not acted, in a timely manner, upon the best information about risk, performance and outcomes, and had not consistently shared risk information with other stakeholders. The provider’s quality monitoring system needed further development and embedding for it to be fully effective. However, we saw that the provider had made widespread improvements across the service. We saw that person-centred care was delivered and that people’s needs were met. Improvements had been made to the environment which we found to be clean, and well-maintained. People received their medicines as prescribed and the service worked closely with health professionals to maintain people’s health and wellbeing. People, and their relatives, had been included in making decisions about their care and participated in regular reviews. Whilst formal feedback systems were yet to be embedded, the people who used the service were consulted on an individual basis, as were their relatives. This service has been in Special Measures since May 2023. The provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. However, we have asked the provider for an action plan in response to the concerns found at this assessment.