Note12 Dec 2025
The provider understood their responsibilities under the duty of candour and displayed last inspection ratings at the service and on their website.
Note12 Dec 2025
People with a learning disability or autism were supported to have maximum choice and control in the least restrictive way.
Note12 Dec 2025
Staff had access to PPE and infection control practices were satisfactory; people confirmed staff wore PPE and washed hands.
Note12 Dec 2025
The provider invested in an electronic recording system to ensure calls are attended, medicines administered, and notes recorded and overseen by the office.
Note12 Dec 2025
Improvements were made to quality systems and auditing processes since the last inspection, including enhanced monitoring of the care system on an on-call/out-of-hours basis.
Note12 Dec 2025
People told inspectors they felt safe whilst receiving care and many were complimentary about the standard of care.
criticalrecord_keeping12 Dec 2025
People's care records and risk assessments were not reviewed after an incident.
minorperson_centred_care12 Dec 2025
The provider was unable to evidence annual survey engagement and feedback improvement plans, from people or their families.
moderatemissed_or_late_visits12 Dec 2025
Reports of staff being late, frequent breakdown of staff vehicles and staff changes without informing the person or the family member.
moderatestaff_competency12 Dec 2025
Staff were not always recruited safely. We found that recruitment and induction processes were not robust.
criticalgovernance12 Dec 2025
The provider's system did not always effectively monitor the quality of care provided to drive improvements.
moderatesupervision_appraisal12 Dec 2025
Staff did not have regular supervision or appraisals of their performance. Staff told us they could not recall the last time they spoke with the registered manager.
moderatestaffing_levels12 Dec 2025
For some staff, we found excessively long shifts from early morning till later at night. This was evidenced by rotas and staff interviews.
moderatestaffing_levels12 Dec 2025
We found on two consecutive visits that the rotas were not complete for the following week, and this was corroborated by discussions with staff.
criticalstaff_training12 Dec 2025
Induction training was completed on the same day for a large percentage of staff, this was a total of 18 courses for 47 staff members out of 57.
criticalcare_planning12 Dec 2025
Risks had not been sufficiently assessed or mitigated and care plans were not always in place to guide staff on how to keep people safe.
criticalincident_learning12 Dec 2025
A person's care plan and risk assessment were not updated after an incident that had occurred.
criticalsafeguarding12 Dec 2025
Records held with the provider and the safeguarding referrals made to the local authority were not always reported by way of notification to CQC.
criticalmedication_management12 Dec 2025
Training matrix record showed that the training course for medication administration was completed the same day as 18 other courses for much of the workforce.
criticalmedication_management12 Dec 2025
Medicine records for as required medication lacked detail for people, eye drops and creams were not always effectively managed as well as risk assessments required for prescribed creams.