Updated 12 November 2024
Date of Assessment: 22 November 2024 to 19 December 2024. The Gardens Care Home provides accommodation with nursing and personal care for up to 56 people. There were 52 people living at the home when we visited, some people were living with dementia. This unannounced assessment was partly due to concerns about management changes, staffing levels and the environment. We visited the home on 22 November and 26 November 2024. We asked the provider to send us further information, which they provided on 19 December 2024. We found 1 breach of the regulations relating to good governance. Inconsistent management oversight had led to significant shortfalls, placing people at risk of harm. This included ineffective record keeping for medicines and treatments and management of safeguarding concerns. Some improvements were needed to the environment to ensure it was safe. There were mixed views from people, staff and visitors about whether staffing levels were appropriate to meet people’s needs. There were some gaps in recruitment records. The provider was unable to evidence staff working in the specialist mental health unit had the correct training, skills and support to fulfil their role. Positive behaviour support plans lacked personalised information to help ensure people were supported consistently and sensitively. Improvements were required to ensure the Mental Capacity Act (MCA) was followed. MCA assessments and best interest decision lacked specific information to allow appropriate decisions to be made in the person’s best interest. Some personal emergency evacuation plans (PEEPS) were not up to date.