Note20 Dec 2023
DBS checks had been undertaken for all staff.
Note20 Dec 2023
The service worked within the principles of the Mental Capacity Act 2005.
Note20 Dec 2023
The manager was receptive throughout the inspection and demonstrated commitment to improve the service.
Note20 Dec 2023
The manager worked in partnership with local authorities, relatives, and attended CQC and local authority forums.
Note20 Dec 2023
Staff completed safeguarding training and knew how to recognise and report abuse.
Note20 Dec 2023
Staff wore appropriate PPE and people were protected from infection risks.
Note20 Dec 2023
Medicines were managed safely with documented administration records and appropriate guidance from health professionals.
Note20 Dec 2023
Risks were assessed and staff took action to mitigate identified risks; relatives expressed confidence in staff's knowledge.
Note20 Dec 2023
Staff understood people's individual care needs and associated risks, responding appropriately to non-verbal communication.
Note20 Dec 2023
Relatives were positive about the quality of care provided by a small, consistent team of staff who knew people well.
minorperson_centred_care20 Dec 2023
The scope and range of questions asked was limited. This restricted opportunities for people to fully comment upon the quality and experience of the care provided.
moderateleadership20 Dec 2023
In response to staff shortages the manager was providing personal care and support to people. This restricted the time available to them to monitor the quality and safety of the service.
moderaterecord_keeping20 Dec 2023
Staff records did not contain all the necessary documents and evidence to support robust recruitment practices.
moderatestaff_competency20 Dec 2023
Satisfactory evidence of conduct in previous employment within the field of health and social care had not been requested. The provider had relied on character references.
criticalgovernance20 Dec 2023
Systems and processes had not been sufficiently developed to ensure the effective assessment and monitoring of the service. This is a breach of regulation 17.
criticalstaff_training20 Dec 2023
Only 24% staff had completed training in moving and handling people, 34% in basic first aid, 31% in food hygiene, and 35% in health and safety.
criticalstaffing_levels20 Dec 2023
There were not always sufficient staff employed to meet people's assessed needs and provide their agreed packages of care.
Note29 Jan 2020
Multicultural and multilingual staff team able to support people's cultural and language preferences.
Note29 Jan 2020
Annual quality assurance surveys conducted with changes made in response to feedback.
Note29 Jan 2020
Medicines system improved since last inspection with personalised medication profiles, stock checks, and competency assessments.
Note29 Jan 2020
Caring and compassionate staff culture evidenced by staff visiting hospitalised service users in their own time.