Note17 Jan 2024
Service exited Special Measures following demonstrated improvements.
Note17 Jan 2024
Provider understood duty of candour responsibilities and was transparent about continued improvements needed.
Note17 Jan 2024
Regular resident and staff meetings took place, and people were engaged in suggesting improvements.
Note17 Jan 2024
Provider appointed a head of service to oversee improvements and worked closely with infection prevention, commissioners and local fire and rescue service.
Note17 Jan 2024
Positive and calm atmosphere in the home with kind and caring staff reported by people and family members.
Note17 Jan 2024
Provider no longer in breach of Regulations 12, 13, 17 and 18 following significant improvements since previous inspection.
Note17 Jan 2024
Sufficient staff on duty to meet people's needs, providing support in a kind and caring manner.
Note17 Jan 2024
Risks to people were assessed, monitored and managed appropriately with systems in place to protect people from harm and abuse.
minorsafeguarding17 Jan 2024
Safeguarding records were maintained and organised. The information in the records would benefit from analysis to identify causative factors or precursors which would identify learning.
minorinfection_control17 Jan 2024
There were shortfalls around cleaning of the laundry area and freezers. The outside bins were overflowing as a result of their position and organisation of the bin area.
moderategovernance17 Jan 2024
Medicines audits were undertaken but improvement was needed to ensure PRN protocols and risk assessments were reviewed.
moderateincident_learning17 Jan 2024
Behaviour charts were used as a record of an incident but they were not written in a way which identified what happened before, during and after the behaviour so learning could be identified.
minormedication_management17 Jan 2024
There were no risk assessments in place for prescribed creams stored in people's bedrooms.
moderatemedication_management17 Jan 2024
Where people were prescribed PRN medicines, guidance was in place but there was no information recorded about the effectiveness of the medicine following administration.