Note7 Dec 2023
Service exited Special Measures following sustained improvements across Regulations 9, 12, 17 and 18
Note7 Dec 2023
Infection control systems in place with PPE provided and used consistently by staff
Note7 Dec 2023
Effective engagement with people and staff through surveys, spot checks and staff meetings for continuous improvement
Note7 Dec 2023
Quality assurance audits covering care plans, risk assessments, medicines and staff files, with spot checks on staff performance
Note7 Dec 2023
Comprehensive pre-employment checks including DBS, identity verification and references
Note7 Dec 2023
Digital call monitoring system in place to verify staff attendance and duration; no missed calls reported
Note7 Dec 2023
Medicines administered safely with staff trained and competency-assessed; previous MAR concern resolved
Note7 Dec 2023
Robust risk assessments in place covering health conditions, falls, mobility and skin integrity following previous breach of Regulation 12
Note11 Aug 2023
Systems were in place to obtain feedback from people and relatives for continuous improvement.
Note11 Aug 2023
Staff had been trained in safeguarding adults and infection control with access to PPE.
Note11 Aug 2023
Care plans were person-centred and included people's preferences, background and support needs.
Note11 Aug 2023
Pre-employment checks were robust to ensure staff were suitable to support people safely.
Note11 Aug 2023
Robust systems were in place to ensure staff attended care calls on time, with significant improvement in timekeeping since last inspection.
moderateincident_learning11 Aug 2023
Failure to take robust action when identifying shortfall during audits meant there was a risk it may happen again.
moderaterecord_keeping11 Aug 2023
The audit findings did not record the action that had been taken to ensure risks of reoccurrence was minimised such as if staff required further training on medicines.
criticalgovernance11 Aug 2023
These audits did not identify the shortfalls we found at the inspection.
moderatemedication_management11 Aug 2023
For one person in March 23, staff did not sign the Medicine Administration Chart (MAR) for the whole month.
criticalcare_planning11 Aug 2023
Risk assessments continued not to be completed in relation to people's health conditions such as people at risk of stroke, heart disorder, respiratory failure and diabetes.