Note3 Oct 2023
The provider responded promptly after the inspection, committing to implement quality audits.
Note3 Oct 2023
The provider worked in close partnership with health and social care professionals.
Note3 Oct 2023
Infection prevention and control protocols were in place and PPE was used appropriately.
Note3 Oct 2023
Staff received regular supervision, attended staff meetings, and felt supported by management.
Note3 Oct 2023
A positive, person-centred culture was in place; people were included in decisions about their care.
Note3 Oct 2023
Risks were assessed and support plans were tailored to each individual, with information communicated to staff.
Note3 Oct 2023
Staff were recruited safely with appropriate pre-employment checks and there were enough staff to support people.
Note3 Oct 2023
People felt very safe and were happy with the care provided; relatives expressed confidence in staff and the registered manager.
moderaterecord_keeping3 Oct 2023
There were no governance systems to ensure medicines, call times, risk management and care planning checks were taking place.
criticalincident_learning3 Oct 2023
The registered manager was not up to date with their responsibilities under the duty of candour. In addition, they were not aware of the requirement to notify CQC of various incidents.
moderatemissed_or_late_visits3 Oct 2023
The provider had no system to monitor calls. They were reliant on people or relative's telling them there had been missed or late calls.
moderatestaff_training3 Oct 2023
There was no effective system to identify when staff required up to date training or to show the level of compliance with training.
moderatemedication_management3 Oct 2023
Staff had not received up to date medicines training or had an assessment of competency. There were no audits taking place of medicines to ensure they were being administered safely.
criticalgovernance3 Oct 2023
Systems had not been established to assess, monitor and improve the safety and quality of the service. This was a breach of regulation 17(1) of the Health and Social Care Act 2008.
Note30 Oct 2021
Management team approachable and responsive, available outside office hours
Note30 Oct 2021
Improvement from Requires Improvement to Good in well-led since August 2015 inspection
Note30 Oct 2021
Accessible complaints process with concerns addressed promptly and to people's satisfaction
Note30 Oct 2021
Person-centred care plans reflecting individual choices, preferences and current needs
Note30 Oct 2021
Staff received regular training in mandatory subjects including safeguarding, moving and handling and dementia awareness
Note30 Oct 2021
Effective medicines management with MAR records and competency checks for staff administering medication
Note30 Oct 2021
Comprehensive risk assessments in place covering environmental, mobility and medication risks