Note16 Jan 2024
Service exited Special Measures following demonstrated improvements; no longer in breach of Regulations 12, 17, or 19.
Note16 Jan 2024
Infection prevention and control policy up to date; staff provided with PPE.
Note16 Jan 2024
Registered manager communicated openly with people and relatives about previous failings and involved them in lessons-learned action planning.
Note16 Jan 2024
Care plans reviewed and updated to provide clear, person-centred guidance including emergency situations such as choking.
Note16 Jan 2024
Staff received upskilled training in oxygen therapy, catheter care, safeguarding, and medicine administration with competency checks evidenced.
Note16 Jan 2024
Staff recruited safely with robust recruitment checklists and appropriate DBS and reference checks in place.
Note16 Jan 2024
Significant improvements to medicine management and administration since last inspection; MAR charts completed in line with best practice guidance.
minorcommunication_with_families16 Jan 2024
more time was required to allow the provider to demonstrate they were able to act on people's feedback and maintain standards going forward.
minorperson_centred_care16 Jan 2024
More time was needed to fully reflect and evaluate on whether people's experience and care provided supported them to meet their goals.
minorleadership16 Jan 2024
the registered manager was working to develop open and trusting relationships with other professional such as the local authority and healthcare professional and more time was needed
moderategovernance16 Jan 2024
more time was required to ensure these new processes and audits identified risks and incidents were actioned appropriately.
Note16 Dec 2023
Regular team meetings and staff supervisions were held
Note16 Dec 2023
Complaints policy in place; one relative reported concerns were acted on quickly by the manager
Note16 Dec 2023
Clear and up-to-date infection prevention and control policy with PPE provision for staff
Note16 Dec 2023
MCA policy in place and staff knowledgeable about Mental Capacity Act principles
Note16 Dec 2023
Staff described by some people as 'kind and compassionate' and 'willing to go the extra mile'
moderateperson_centred_care16 Dec 2023
The culture was not consistently person centred and the provider did not record outcomes for people.
criticalleadership16 Dec 2023
The provider did not understand the principles of good quality care and had not developed systems and processes to ensure compliance with regulations.
moderateincident_learning16 Dec 2023
We found no action had been taken to embed a culture of learning lessons from previous incidents.
criticalrecord_keeping16 Dec 2023
Gaps were identified in MAR charts. Staff had not recorded why these medicines had been administered and audits had failed to identify these gaps.