Note6 Jun 2023
Management team demonstrated good understanding of equality, diversity and protected characteristics reflected in care records.
Note6 Jun 2023
Staff received training in PPE use and infection control with no reported issues from people or relatives.
Note6 Jun 2023
Service working within principles of the Mental Capacity Act; staff understood responsibilities regarding capacity and best interests.
Note6 Jun 2023
Staff felt supported by management and described a positive, family-like workplace culture.
Note6 Jun 2023
Medicines were administered safely by trained staff, with regular senior competency checks.
Note6 Jun 2023
Care plans were completed, reviewed regularly, and signed by people receiving support — an improvement from the previous inspection.
Note6 Jun 2023
Staff demonstrated in-depth knowledge of the people they supported, mitigating gaps in risk assessments.
Note6 Jun 2023
Safe recruitment practices fully restored; all pre-employment checks including DBS completed, resolving previous breach of Regulation 19.
minorincident_learning6 Jun 2023
Feedback provided to the service was not used to support quality improvement. People had completed surveys, but these had not been analysed to understand themes.
minorcommunication_with_families6 Jun 2023
People and relatives views about communication with managers was mixed. This related to call times and not always being informed if calls would be late or missed.
moderatemissed_or_late_visits6 Jun 2023
One relative said, 'I wouldn't recommend them due to not turning up.'
minormedication_management6 Jun 2023
Medicines audits required further improvement, to ensure they were completed in a timely manner to ensure mistakes are followed up straight away.
moderatesupervision_appraisal6 Jun 2023
The management team did not always record when spot checks of staff practice had taken place so could not be fully assured all staff were competent in their roles.
moderatecare_planning6 Jun 2023
Risk assessments were not always completed or did not record full information about risk. For example, we found one person did not have a falls risk assessment.
moderategovernance6 Jun 2023
The management team had not used audits to identify gaps in care plans and risk assessments. This meant that some care plans lacked up to date information.