Updated 16 January 2025
Date of Assessment: 23 January 2025 and 6 February 2025 with the site visit taking place on the 23 January 2025. The service is a residential care home service providing support to older people living with dementia. We were following up on warning notices made after the last inspection. There had been breaches in Regulation 17 Good Governance and Regulation 15 Premises and Equipment. In addition, requirement notices were served for Regulation 12 Safe and Treatment, Regulation 11 Need for Consent and Regulation 17 Good Governance. This required the provider to send an action plan on how they would make changes to meet the standards. We received an action plan outlining what they would do and by when.
At this visit we looked at 3 domains of Safe, Effective and Well-Led. The provider had a good learning culture and people could raise concerns. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met people’s needs; however, they were not always well-maintained, and the manager had mitigated risks of the maintenance and any risks to people. For example, if a person needed a sling to be moved with a hoist, they had their own, cleaning items which were locked away. The manager had improved their auditing of the service for example, doing weekly medicines audit. There were medicine protocols for all medicines people had been prescribed, they described amounts, possible side effects and actions for staff to take.
There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. However, they did not always manage the storage of medicines well and they did not always involve people in planning any changes. This was an area for improvement and the provider took action to address this. Staff reviewed assessments taking account of people’s communication, personal and health.