Note23 Apr 2021
Provider was no longer in breach of Regulation 17 (governance) or Regulation 19 (fit and proper persons) following previous requires improvement rating.
Note23 Apr 2021
Strong governance improvements since previous inspection, including electronic audit systems for care plans, medicines, infection control and recruitment.
Note23 Apr 2021
Care plans were person-centred, co-produced with individuals, and covered all protected characteristics under the Equalities Act 2010.
Note23 Apr 2021
Registered manager promoted an open, transparent culture and was well known and accessible to people using the service.
Note23 Apr 2021
Staff training was up to date; new staff completed induction and shadowing before working independently.
Note23 Apr 2021
Robust risk assessments with detailed management plans including triggers and actions to keep people safe.
Note23 Apr 2021
Electronic medicine recording system with alerts implemented to ensure timely administration and safety.
Note23 Apr 2021
People were involved in recruiting new staff, including participating in interviews and providing feedback on staff performance.
Note14 Jan 2020
People were supported to maintain and develop independence, with flexible staffing arrangements in place
Note14 Jan 2020
Open and transparent culture with staff describing the provider as passionate, supportive and client-led
Note14 Jan 2020
Staff received regular one-to-one supervision and the provider maintained a visible, approachable leadership presence
Note14 Jan 2020
Recovery plans were developed collaboratively to support people's goals and mental health journeys
Note14 Jan 2020
Care plans were detailed and person-centred, with people involved in writing and reviewing their own plans
Note14 Jan 2020
Incidents were fully recorded and investigated with learning shared across the staff team
Note14 Jan 2020
Medicines were managed safely with staff trained and competency-checked regularly by the provider
Note14 Jan 2020
People and relatives consistently reported feeling safe and well supported, with positive feedback about staff knowledge and caring approach
moderateconsent_capacity14 Jan 2020
Some measures in place to keep people safe from harm were of a restrictive nature...thought had not always been given to informed decision making to enable the least restrictive option
moderatemedication_management14 Jan 2020
The medicines audit was not completed as regularly as it should have been...individual MAR's were only checked once every five months.
moderatecare_planning14 Jan 2020
Some areas assessed as being high risk had a one sentence description of how to keep people safe. For example, 'to have regular activities and support'
moderaterecord_keeping14 Jan 2020
Another member of staff did not have an application form on file. There was no evidence of past employment history or education.
criticalstaff_competency14 Jan 2020
The failure to ensure a robust system is in place to recruit only suitable staff is a breach of Regulation 19 of the Health and Social Care Act 2008
criticalgovernance14 Jan 2020
The failure to ensure a robust approach to monitoring the quality and safety of the service is a breach of Regulation 17 of the Health and Social Care Act 2008