Updated 20 March 2024
Date of assessment 8 May to 27 June 2024. The assessment was in response to concerns we had received about the quality and safety of people’s care, the cleanliness of the environment, staff training and support, and the culture of the service. We have found 2 breaches of the regulations in relation to safe care and treatment, and good governance. Systems and processes which monitored the quality and safety of people’s care and treatment, and their living environment were not always robust. Some of the shortfalls found had not been identified by the provider. People’s needs were not fully assessed or risk assessed in some key areas to promote safety. People with specific health conditions and known risks had been placed at risk of receiving unsafe care. The provider took action to address the high risk areas with regards to the treatment of specific health conditions, by seeking and responding to guidance and support from external professionals. The environment and equipment was not always clean, with malodours present. Medicine systems did not fully support the monitoring of people’s care and treatment. The provider’s managerial structure was clear in terms of roles and accountability. Audits and reports were undertaken and the outcome escalated, which referred to any improvements required along with the action to be taken to address shortfalls in many areas. Systems of analysis and learning from incidents was in place. Staff spoke positively of the support they received from the management team and told us there were sufficient staff to meet people’s needs. Staff achievement was recognised by the provider. Staff were aware of their role and responsibilities in keeping people safe.