Updated 15 November 2024
Date of Assessment: 4 December 2024 to 9 December 2024. The service provides nursing and personal care to older people, some of whom were living with dementia. We found 1 breach of regulation in relation to good governance. Due to a lack of robust management oversight, the service did not always have safe systems for medicines administration and record keeping. This included the use of thickening agents and topical medicines. Following our inspection the provider implemented changes to improve medicines systems. However, the full effects of these changes could not be measured until they were embedded into practice. There were also incidents and potential safeguarding concerns which had not been notified to CQC as expected. This was dealt with outside of the assessment. Improvement was needed to the quality of records. Some records contained gaps and others were not completed at all. For example, further information was needed in the fire risk assessment, other health and safety checks were completed appropriately. There were delays in applying for Deprivation of Liberty Safeguard authorisations, once they had expired, and Mental Capacity Assessments were completed for people who had capacity to make their own decisions. Care plans required more person-centred information. The provider was unable to demonstrate complaints were logged. Records showed new staff were recruited safely. However, there were no induction records for agency staff.