Updated 3 December 2024
Date of Assessment: 13 February to 20 February 2025. The service is a residential care home providing personal care and accommodation to older people and including those living with dementia. There were 23 people using the service at the time of our assessment. We found 5 breaches of regulation relating to person centred care, consent, risk management, governance and staffing.
The provider did not ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated. Not all care and support practices were safe. Not all care plans accurately reflected all of a person’s care and support needs.
Whilst people and those acting on their behalf were generally happy with the care and support provided, not all care and support provided by staff was person centred to meet people’s needs. The deployment of staff within communal lounge areas left people without sufficient staff support. Observations of staff’s practice did not provide assurance staff were skilled and competent to effectively apply their learning in their everyday practice. People received limited opportunities to participate in meaningful activities. Not all staff had received regular supervision, or an appraisal of their overall performance.
People’s capacity to consent to care and support had not always been assessed in line with the Mental Capacity Act 2005 [MCA]. Where people had an authorised Deprivation of Liberty Safeguards [DoLS] in place with conditions imposed, there was no evidence to demonstrate these had been reviewed and actioned to ensure compliance with the MCA. Not all DoLS had been renewed in a timely manner prior to them expiring. The records for MCA assessments viewed were confusing.
Governance systems were not effective in identifying or addressing areas for improvement.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.