Note21 Feb 2023
Positive partnerships with health and social care professionals, commissioners and social workers.
Note21 Feb 2023
Person-centred culture with easy-read welcome brochure, individualised communication support and meaningful activities.
Note21 Feb 2023
Staff meetings and monthly supervision took place routinely; staff felt listened to and engaged in service improvement.
Note21 Feb 2023
Governance and quality assurance processes were strengthened; registered manager had clear oversight of the service.
Note21 Feb 2023
Strong learning culture with incident review, updated risk assessments and care plans following adverse events.
Note21 Feb 2023
Infection prevention and control measures were fully assured across all assessed criteria.
Note21 Feb 2023
Medicines management processes were improved, including GP summaries and pre-stay medication checks with families.
Note21 Feb 2023
Safeguarding procedures were strengthened since the last inspection; staff felt confident raising concerns with leadership.
Note21 Feb 2023
Personal risk assessments were regularly reviewed and updated; emergency and fire evacuation plans were in place and well understood by staff.
moderaterecord_keeping21 Feb 2023
We identified a shortfall within the recruitment process which limited the providers oversight and opportunity for staff recruitment histories and references to be adequately scrutinised.
Note31 Aug 2022
Provider met duty of candour responsibilities and apologised when things went wrong.
Note31 Aug 2022
Regular supervisions and team meetings were held; staff gave positive feedback about support received.
Note31 Aug 2022
Management were visible, approachable and engaged positively with people, families and professionals.
Note31 Aug 2022
Staff felt respected, supported and valued; able to raise concerns without fear.
Note31 Aug 2022
Registered manager set a culture valuing reflection, learning and improvement and was receptive to challenge.
Note31 Aug 2022
Staff understood MCA principles and appropriate DoLS authorisations were in place.
Note31 Aug 2022
Effective infection prevention and control measures were in place, with good PPE use and clean premises.
Note31 Aug 2022
Staffing levels were sufficient including one-to-one support; agency staff used were already familiar to people.
Note31 Aug 2022
Staff understood and implemented STOMP principles ensuring medicines were reviewed by prescribers appropriately.
moderateother31 Aug 2022
a fire drill was supposed to take place every three months. However, only one fire drill was recorded for 2021 and one fire drill for 2022.
criticalstaff_competency31 Aug 2022
not all staff signed the document to confirm they were familiar with people's care plans... staff did not always follow appropriate guidance when working with the person.
moderategovernance31 Aug 2022
Governance processes were not always effective and did not always hold staff accountable, keep people safe, protect people's rights and provide good quality care.
moderateincident_learning31 Aug 2022
The service did not always manage incidents affecting people's safety well. Staff recognised incidents but did not always report them appropriately.
criticalsafeguarding31 Aug 2022
The provider had no effective system in place that could provide staff with information about their responsibilities and where to escalate their safeguarding concerns.
criticalrecord_keeping31 Aug 2022
one person's epilepsy protocol stated they needed to be checked on every 30 minutes, however their risk assessment stated the checks were to be completed every 15 minutes.
criticalcare_planning31 Aug 2022
one person's epilepsy protocol had not been reviewed since 2016 and contained out-of-date information about the person's medicines.
Note30 Oct 2021
Accessible complaints procedure available in easy-read pictorial format; concerns addressed openly
Note30 Oct 2021
Service designed in line with Registering the Right Support values: choice, independence and inclusion
Note30 Oct 2021
Effective quality assurance systems including regular audits with action plans to drive improvement
Note30 Oct 2021
New management team created an open, transparent and supportive culture boosting staff morale