Updated 14 May 2025
Date of assessment: 03 September 2024 to 31 January 2025
We carried out a responsive assessment of the medical care including elderly care service due to receiving an increased number of concerns and complaints from different sources. The service was outstanding at the last inspection. We assessed 22 quality statements across safe, effective, caring, responsive and well-led key questions and have combined the scores for these areas with scores from the last inspection. We believe the quality of care has declined, meaning the rating is likely to change.
We found 2 breaches of the legal regulations in relation to safe care and treatment and governance.
At this assessment, we found the service was underperforming and not always meeting expectations. A proactive and positive safety culture was not embedded, and lessons were not always learnt or disseminate to staff. The service used systems and patient pathways however there were issues with the timeliness of assessing clinical risk. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. The service did not always have enough qualified, skilled and experienced people to keep people safe. The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. People and communities were not always at the centre of how care was planned or delivered. Leaders were not visible and did not always communicate effectively with staff. Their Governance was not clear or effective and management systems were not always effective to monitor safety, quality and performance in the services.
However, staff understood how to protect patients from abuse and worked together to care for people that used their services. The service provided care based on national guidance and evidence-based practice. People were treated with kindness, empathy and compassion. The service had a vision for what it wanted to achieve and a strategy to turn it into action.
We have asked the provider for an action plan in response to the concerns found at this assessment.