Updated 7 January 2025
Date of Assessment: 14 January to 27 January 2025
The assessment was in response to concerns regarding risk management.
The service is a nursing home providing personal care and support to older people some of whom are living with nursing needs and/or dementia.
Risk assessments were not always up to date and consistent. Environmental risks were not always addressed in a timely manner which placed people at risk of harm. Clinical risk monitoring was not always robust, but staff were proactive in escalating concerns so people received the care they needed. Staff had the right skills and qualifications to meet people’s needs but there were insufficient staff at night to ensure people’s safety in an emergency. Medicines were stored safely but some gaps in medicine administration records (MARs) had not been picked up. Mental capacity assessments and best interests’ meetings had not always been completed when needed which meant the provider could not be assured lawful decisions were being made.
Quality checks were not always sufficiently robust to ensure concerns were identified and action taken to reduce the risk of reoccurrence. Staff did not always feel heard by leaders but were confident any concerns regarding people living at the home would be responded to.
People felt safe and were happy living at the home. People were supported by staff and leaders who were person-centred and treated them with kindness and compassion. Managers ensured staff received training and regular supervision and appraisals to ensure they were skilled and knowledgeable to meet people’s needs. People were given choice and opportunity, and proportionate risks were taken to enable people to engage in activities they enjoyed.
The provider was in breach of regulation in relation to the governance of the service due to systems in place not being sufficiently robust to ensure adequate oversight.
We have asked the provider for an action plan in response to the concerns found at the assessment.