Updated 29 April 2025
Date of assessment 08 May 2025 to 02 July 2025.
The inspection was carried out as the service had not previously been inspected and following concerns raised regarding a person’s personal care, which had been resolved before the inspection took place.
We reviewed all key questions and quality statements under the domains of Safe, Effective, Caring, Responsive and Well-led.
We found people were safe and protected from abuse and avoidable harm. Where concerns had been identified, the provider took action to prevent reoccurrence. There were systems in place to support safe care pathways and transitions. The environment was safe, clean and well maintained, and people had access to the equipment they needed to remain safe. Regular safety checks were being regularly completed by the service. There were sufficient numbers of qualified, skilled and experienced staff who received regular supervision and support. Staff and teams worked well together.
There was evidence of people being treated with kindness, dignity and respect and people were supported to be independent and have control over their lives. Care and treatment were evidence-based which meant the service used the best available information based on up-to-date research. The service also helped people plan for future.
There was a clear and inclusive leadership structure in place, with a shared vision and culture that reflected the values of the service. Leaders demonstrated a strong partnership with the community and had been innovative in the design of the building and implementing initiatives to support people’s overall well-being.
However, we identified some risks were not being managed in accordance with people’s care plans. For example, one person’s care plan contained conflicting information about their history of falls, which had not been identified through the provider’s internal audit processes. Additionally, guidance for the administration of PRN (as needed) medicines was not always clear, specifically, whether the stated maximum dose referred to a single administration or a 24- hour period. Whilst no harm had occurred to people as a result of the concerns found, the registered manager and clinical lead were responsive when the concerns were raised and outlined the actions they would take to address them.
We also identified an incident involving an unwitnessed fall that resulted in hospital admission. This incident had not been reported to the Care Quality Commission (CQC) or the local authority. When this was brought to the registered manager’s attention, they acknowledged the oversight and confirmed the incident should have been reported in line with statutory requirements.