Note4 Aug 2022
The provider understood duty of candour responsibilities and apologised to people when things went wrong.
Note4 Aug 2022
People with swallowing difficulties were supported using the IDDSI Framework, with food and drinks prepared safely.
Note4 Aug 2022
A new senior management team implemented a service improvement plan prior to inspection and had made considerable progress.
Note4 Aug 2022
The service worked within the principles of the Mental Capacity Act and appropriate DoLS authorisations were in place.
Note4 Aug 2022
Recruitment was conducted safely, including DBS checks and references before staff worked with people.
Note4 Aug 2022
Staff followed STOMP principles, ensuring behaviour was not controlled by excessive or inappropriate use of medicines.
Note4 Aug 2022
Staff understood safeguarding responsibilities and could describe types of abuse, signs of concern, and reporting procedures.
moderateincident_learning4 Aug 2022
We saw evidence that encouraged reflective practice following medicines incidents however, we did not see evidence to prevent future occurrences.
minorinfection_control4 Aug 2022
Staff did not consistently wear PPE in line with the guidance and providers policy.
moderatecommunication_with_families4 Aug 2022
One relative said, 'I haven't seen the care plan and there's quite a few times that the phone hasn't worked for weeks and weeks.'
moderateleadership4 Aug 2022
Staff did not consistently know and understand the provider's vision and values. One staff member said, 'I don't know what [the Provider] wants and I don't know what they stand for.'
moderatestaffing_levels4 Aug 2022
people had not always received correct staffing levels or expertise from staff who knew them well.
criticalcare_planning4 Aug 2022
People who have a diagnosis of epilepsy did not always have clear guidelines and protocols for staff to follow to support them safely.
moderatemedication_management4 Aug 2022
for one person we could not see the record to support the decision to give medicine covertly.
moderatemedication_management4 Aug 2022
we could not be assured that other medicines information in care records was always up to date or readily available when needed.
criticalrecord_keeping4 Aug 2022
records relating to people's care were not always comprehensive and up-to-date. This placed people at risk of harm.
criticalgovernance4 Aug 2022
systems were either not in place or robust enough to demonstrate the service was effectively managed. This placed people at risk of harm. This was a breach of regulation 17.
Note30 Oct 2021
Supportive induction process praised by new staff members.
Note30 Oct 2021
Service worked closely with GPs, district nurses and other health professionals to support people's needs.
Note30 Oct 2021
Provider demonstrated openness and duty of candour throughout the inspection.