Updated 9 August 2024
Date of Assessment: 2 April to 3 June 2025 with site visits on 2 April, 3 April and 8 April 2025. The service is a nursing home providing support to older people and younger adults living with dementia, nursing needs and physical disabilities. At the time of assessment, there were 57 people using the service. The assessment was prompted due to information of concern we received regarding accidents and incidents and the falls management. There was a registered manager for the service. We found 3 breaches of regulation in relation to safe care and treatment, staffing and governance.
The facilities and equipment did not always meet people’s needs, they were not always clean and well-maintained, and some risks were not always mitigated. We found some concerns with staffing in relation to training compliance and the induction of agency staff. Managers had not made sure staff received required training and competency assessments and regular appraisals to maintain high-quality care. Staff did not always manage medicines well, however, involved people and families in planning any changes.
The provider did not always have clear responsibilities, roles, systems of accountability or good governance in relation to governance meetings frequency, audit completion and audit oversight. Leaders had the skills, knowledge, experience and credibility to lead effectively. However, the provider could not demonstrate a robust induction, development and supervision for all staff. The provider could not demonstrate there was a robust governance process assessing the culture of the service and the quality of care being delivered regularly. However, the provider had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks and staff felt supported to give feedback and were treated equally, free from bullying or harassment.