During an assessment under our new approach
Date of Assessment: 03 June to 24 June 2025. This service is a residential care home providing support to older people with physical difficulties, sensory impairments, mental health issues and adults living with dementia. This inspection was carried out due to concerns we received regarding the safe use of equipment. We found no evidence during this inspection that people were at risk of harm from this concern.
The provider had a good learning culture and people could raise concerns. The provider investigated incidents thoroughly and lessons learnt were shared with the staff team. Staff understood and managed risks safely. The facilities and equipment met people’s needs, and staff ensured these were clean and well-maintained. There were enough staff on duty to support people safely. Staff received training and knew people well. People’s medicines were administered safely and regularly reviewed. However, where the provider monitored environmental risks such as fire checks, there were gaps in the recordings, some areas of the physical environment needed refurbishment, and the medicines fridge was not being accurately recorded.
People were involved in regular assessments of their needs. People had enough to eat and drink to stay healthy. Staff worked with all agencies involved in people’s care to achieve the best outcomes for people. Staff monitored people’s health to support healthy living. The provider considered people’s best interests where they did not have capacity to make informed decisions. However, whilst care plans were regularly reviewed, some care plans contained both current and historical information which at times conflicted.
Leaders and staff had a shared vision and culture based on valuing and upholding people’s rights. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. The registered manager and staff understood their roles and responsibilities. Governance systems, including quality audits, were in place ensuring people’s care was regularly monitored and reviewed. There was a culture of continuous improvement. However, whilst staff felt supported to give feedback and raise concerns, some staff felt the provider needed to be more flexible to accommodate their needs. The provider promptly responded our feedback and took action to address any areas of concern.
The provider was previously in breach of the legal regulation in relation to safe care and treatment and overall governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.