Updated 28 March 2025
Date of Assessment: 24 April 2025 to 02 May 2025.
This assessment was carried out in response to concerns received about staff knowledge and skills in relation to meeting people’s support needs. This included how falls were managed and medicines management.
The registered manager promoted a positive learning culture and people could raise concerns.
Staff received training in safeguarding. Recent safeguarding referrals had been made appropriately.
There were enough staff to meet people’s needs. Systems and procedures for recruiting new staff were robust. Staff received training and completion of this was monitored.
There were effective processes to prevent and control infection. Regular audits were carried out to oversee the cleanliness and safety of the environment.
People’s medicines were mostly managed safely. However, there was some lack of sufficient individualised and personalised information within people’s medicines records.
People’s needs were assessed face to face prior to moving to the service. Care plans and risk assessments were sometimes generic and did not always contain clear guidance for staff.
People had not always been assessed for their mental capacity to consent to all aspects of their care. Additionally, not all mental capacity assessments we looked at were decision specific.
Systems and processes to assess, monitor and improve the quality and safety of the service were in place and mostly operated effectively. While we found there were areas for improvement within the service, the provider’s continuous improvement plan showed actions were taken when shortfalls in service provision were identified.
The provider had plans for ongoing refurbishment of the environment, and we saw evidence of work completed and in progress.
We received positive feedback from external health and social care professionals about how the service worked in partnership with them.