Updated 21 March 2024
Date of assessment 16 May to 09 July 2024 . This assessment was carried out to follow up on concerns raised around pressure ulcer management, person centred care, safe and effective staff, and safe environment. Overall, we looked at 9 quality statements in Safe, Effective, Caring and Well Led. We have not previously rated this service under its current provider. This assessment did not cover all parts of our Single Assessment Framework, therefore we have only updated scores and ratings for those areas which we have assessed. During this assessment we found 3 breaches of the legal regulations in relation to safe care and treatment, good governance and safe and effective staffing. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. We carried out on-site visits and also reviewed documents off-site. On the day of our on-site visit, 21 people were being supported. Care planning and risk assessments did not always include sufficient detail to help staff understand how people need to be supported to manage their health care needs. Staffing levels did not always meet people’s needs. Staff were not always available in communal areas in line with people’s falls risk assessments and people we spoke with felt staff were sometimes rushed. Staff training records did not reflect staff training and competency checks around dysphagia and dementia. We have asked the provider for an action plan around this. We observed staff offering people choices and promoting people's independence. However, we found assessments of people’s capacity had not always been carried out appropriately to assess whether people could make decisions about their care. The provider had not established effective governance systems to monitor, evaluate and improve quality and safety of the the service external audits and feedback from others.