Updated 3 April 2024
Date of assessment: 24 April 2024. This was a responsive assessment due to concerns received about the culture of the service. However, we found no evidence of closed or poor culture during our assessment. Quality governance systems were either not in place or not robust to ensure effective monitoring. However, as the service was still small and staff knew people well this risk was somewhat mitigated. We have recommended the provider ensure they implement and embed quality governance systems going forward. There were also missed opportunities to engage with other partnership agencies or external stakeholders. Despite this, there was an inclusive and caring ethos within the service, in which staff felt confidence in the management team. Staff were aware of their responsibilities to safeguard people and keep them from harm by ensuring risk mitigation processes were followed. Staff were safely recruited, and a monitoring system ensured staff were staying the full length of time with people during care calls. Infection prevention and control processes were in place to keep people safe.