During an assessment under our new approach
Date of assessment: 30 June, 2 and 3 July 2025. The service is a care home without nursing providing support to older people and people with dementia. At the time of our visit, there were 12 people using the service. This assessment took place due to concerns received about people’s care, risks, medicine, staffing and governance oversight at the service. We found the provider was in breach of the legal regulations relating to medicine, safety of premises and equipment, staff recruitment, need for consent and good governance. The registered manager did not always ensure they had robust quality assurance systems and governance processes which operated across all levels of the service. The provider had not always followed their own policies or best practice guidance to effectively assess, monitor and mitigate any risks relating to the health, safety and welfare of people using the service and others. This included not using safe recruitment procedures to employ staff, not ensuring premises and equipment were safe to use including water and fire safety and medicines records keeping. This put people at increased risk of harm.
The facilities and equipment were mostly clean and maintained for infection risks to be mitigated. However, more needed to be done around tidying the environment and further refurbishments. The environment was not always dementia-friendly and needed more improvements. The provider needed to review and improve staff deployment and how staff's training needs and skills were managed in order to meet people's specific needs. People did not always have meaningful activities and opportunities to pursue their interests in their local area with others. People’s relatives were involved in reviewing and planning their care. However, we were not assured people’s views and decisions were fully considered. The provider did not ensure capacity assessments and best interest decisions were carried out with people when needed to support people’s decisions and consider their wishes. We were not always assured the provider and staff were working together to ensure the risks of a closed culture were minimised so that people received support based on transparency, respect and positive culture in the service. While staff did not always feel supported by the registered manager, they told us they would still report any concerns as they recognised their duty to keep people safe. Staff were not always encouraged to be actively involved in the development and continuous improvement of the service. Staff told us how they protected people from abuse and how they would report incidents, accidents and other concerns. Staff had training on how to recognise and report abuse and they knew how to apply it. The service worked with other agencies to do so. Staff ensured people were protected from the risk of acquiring an infection during the provision of their care. Staff supported people to access different services and support from health and social care professionals to promote and achieve positive outcomes for people. We have asked the provider for an action plan in response to the concerns found at this assessment.