During an assessment under our new approach
Date of assessment: 25 March 2025.
The assessment was completed in response to concerns we had received about the service. The service is a residential care home for up to 66 people. At the time of assessment there were 55 older people living at the home. This service is run by 2 registered providers who are dual-registered. This means both providers are responsible for service delivery at the location.
The providers demonstrated a strong commitment to safety through proactive investigations, staff engagement, and collaboration with stakeholders. People felt safe, and staff were confident raising concerns, which led to meaningful changes. Care systems supported smooth transitions and continuity. Staff were well-trained and appropriately resourced. Infection control procedures were effective, and the premises were well-maintained. Medication management was robust, with regular audits and competency checks. Overall, the providers maintained a safe and responsive care environment, though some improvements were needed in care documentation and evacuation planning.
The service assessed people’s care needs thoroughly before and during their time living at the service, including hospital readmissions. Electronic care plans and recognised tools like MUST supported this process. Staff collaborated effectively with families and healthcare professionals, ensuring timely medical support and involving people in care planning. The providers prioritised wellbeing, independence, and nutrition through proactive monitoring and referrals. Assessments under the Mental Capacity Act 2005 were generally good, although quality varied. Staff demonstrated respectful, person-centred care and understanding of least restrictive practices. Overall, the approach promoted personalised support and safeguarded people’s health, choice, and dignity.
Staff provided respectful, culturally aware care, showing genuine kindness and attentiveness to people's dignity, privacy, and religious preferences. Communication needs were well understood, with assistive technology supporting those with sight and hearing loss. While personal interests and aspirations were not always addressed, efforts were underway to improve activity provision. Staff were readily available, responded quickly, and maintained positive relationships. Concerns were addressed, and healthcare referrals were made promptly. Staff felt supported in their roles, with regular supervisions and future access to wellbeing resources. Some care notes lacked respectful language, which the providers committed to resolving. Overall, the environment reflected compassion and teamwork.
Care records were inconsistent and contained insufficient detail, especially in personal histories and daily logs. Despite some thoughtful entries, conflicting information undermined care planning. Staff used an electronic system to document interventions and health professional input. Communication needs were well-assessed, and inclusive formats were available. Residents’ views were actively sought through meetings and a Resident’s Ambassador. Surveys informed action plans, with most staff-related actions completed. Staff demonstrated strong understanding of individual needs and ensured swift health referrals. End-of-life care plans existed but lacked personal detail. Staff were trained and committed to providing compassionate end-of-life support.
The provider implemented a vision strategy rooted in transparency, equality, and inclusion, aiming to support staff with protected characteristics and ensure fair treatment and care. Leadership was visible and valued, with the Registered Manager and Deputy Manager fostering teamwork through supervision and wellbeing support. Staff felt empowered to speak up and reported high morale and mutual respect. Although quality audits missed issues in care records, corrective action and training were promised. Collaborative efforts with healthcare partners were effective, and continuous improvement was evident, including enhanced activities and staff education through external experts, demonstrating commitment to person-centred care and service development.