Note13 Sept 2023
The provider was responsive to inspection findings and submitted an action plan detailing improvements.
Note13 Sept 2023
People lived in a clean and pleasant environment.
Note13 Sept 2023
Staff supported people to keep in touch with family through video and phone calls during visiting suspension.
Note13 Sept 2023
People and relatives gave consistently positive feedback, with staff described as 'marvellous', 'very kind' and 'absolutely first class'.
Note13 Sept 2023
Robust infection control procedures were in place which helped keep people and staff safe during the COVID-19 pandemic.
Note13 Sept 2023
Staff recruitment processes were safe with all required checks completed before new staff started employment.
moderatecare_planning13 Sept 2023
One person had fallen frequently which resulted in serious injury on two occasions but their assessment showed they were at low risk of falls.
moderatestaffing_levels13 Sept 2023
The provider had no formal system in place to calculate safe staffing levels. Duty rotas showed these levels were not maintained.
moderaterecord_keeping13 Sept 2023
Care records for people using the service were not always accurate or up to date. Risk assessments and care plans were not always accurate or updated when needs changed.
criticalleadership13 Sept 2023
There was a lack of effective management and leadership. Staff described managers as friendly and approachable however, they said issues raised were not always acted upon.
criticalgovernance13 Sept 2023
The analysis for December 2020 showed a total of 5 incidents in the service yet our review found 23 incidents. This included multiple falls and incidents between people using the service.
criticalincident_learning13 Sept 2023
People were having multiple falls yet there was no evidence of learning or action taken to prevent repeat events.
criticalsafeguarding13 Sept 2023
The provider did not always report safeguarding incidents to the local safeguarding authority and CQC. For example, incidents between people who used the service.
criticalmedication_management13 Sept 2023
Topical medicine administration records (TMARs) were not always in place for prescribed creams to ensure staff knew how, where and when to apply them.