During an assessment under our new approach
People were exposed to avoidable risks due to ineffective oversight systems and processes. Risks were assessed and managed when people first began using the service. However, people’s needs and risks were not consistently reviewed, either regularly or before each respite stay, despite care plans containing clear, good quality guidance for staff. The provider was responsive and made improvements.
We found improvements were needed in relation to medicines management and staff recruitment procedures and training. Despite this staff worked well together and demonstrated an understanding of their responsibilities to provide safe care while promoting people’s rights, wellbeing, independence and dignity.
We found restrictive practices were used without appropriate professional oversight or lawful best interest decision-making processes being completed. The provider was responsive and some took action including removing unnecessary restrictions and they confirmed an application for legal authorisation had been requested.
Systems were in place to record and report accidents and incidents, and staff understood their responsibilities in this area. However, these were not always analysed to identify trends or patterns to reduce future risks.
People lived in a clean and tidy environment, and bedrooms were personalised. However, environmental risks were found including lack of fire safety equipment, and the absence of systems to ensure compliance with fire safety, water safety and wider health and safety requirements. Records did not provide sufficient assurance there was regular cleaning to prevent the risk and spread of infection.
Staff supported people to make day to day decisions and respected their wishes. Staff promoted people’s privacy and dignity and encouraged them to live fulfilling lives and supported them to social and pursue their hobbies and interests. Staff supported people to make healthier food choices to promote their health and wellbeing. Staff were kind and attentive.
Safeguarding processes were in place, and staff were able to identify signs of abuse and understood how to report concerns. Staff demonstrated good knowledge of the people they supported, including their individual communication needs, and responded to them appropriately.
Staff told us they enjoyed their work, had opportunities to develop and felt respected and were treated fairly by the provider. Staff were confident to raise concerns and speak up without fear. There was a complaints procedure in place. The service had not received any complaints
The governance systems and processes were not effective in identifying areas for improvement. Further action was required to strengthen and embed governance arrangements to drive improvement. Opportunities to engage with external partners and the wider community remained limited.