Updated 11 March 2024
We assessed this service from 30 April to 14 June 2024. We carried out this assessment because of safeguarding concerns and complaints we received. Some people and their relatives told us about issues they had experienced with elements of poor care and communication. However, in general people and their relatives told us they were happy with the support staff provided. Staff knew how to report a safeguarding concern and the action to take following an incident. They had regular training and supervision. However, some staff told us feedback to improve the quality of care provided and ensure people’s safety was not taken seriously or acted upon by some current and previous senior staff and they had significant concerns about staffing levels. Concerns were raised regarding the skills of some staff, and we observed some staff not effectively communicating or responding to people, particularly during lunchtime. We found evidence that a number of people have been assessed as high risk of malnutrition. One relative told us that staff have 'no time to sit with people and give them time.’ Staff told us 'people can have to wait hours for their personal care and if you rush you do mess up, creams get missed’. Staff said there are 'a lot of incidents where people get aggressive, no time to calm down and talk to them.’ Since the last inspection there continues to be improvements required in relation to safe medication management. We found 3 breaches of legal regulation in relation to good governance, safe and effective staffing and safe care and treatment. Governance systems were not effective in addressing areas for improvement. Care plan audits did not identify insufficient information in care plans to guide staff. Medication audits did not identify expired medication. We have asked the provider for an action plan in response to the concerns found at this assessment. Although care plans included guidance from other services they were not always up-to date, or person centred.