Handsale Limited - Silver Trees Also known as Laurel Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement and the provider was in breach of legal regulation in good governance. At this assessment the rating has remained requires improvement as we found improvements were still needed to the provider’s quality assurance systems as we found some shortfalls in the management of medicines and staff practice. This meant the provider was still in breach of legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance and management systems were still not always operating effectively to identify and mitigate risks to service users during our inspection.

The provider’s medicines audits had identified where ongoing improvements were needed to the completion of people’s MAR charts. For example, there had been gaps in recording allergy information and signing when medicines were administered. They had implemented a system where daily checks were completed. However, these daily checks had not improved the documentation where 2 people needed their medicines recorded on 2 occasions and where allergy information was needed. Audit processes had also not identified where topical creams were not being stored safely and securely.

During our visit, we observed poor practice where 2 staff were not wearing personal protective equipment as per government guidance and where 1 person was being wheeled unsafely in their wheelchair. We raised this and the other shortfalls with the registered manager. They confirmed they were taking immediate action following us raising this with them. The area manager also confirmed they were increasing their weekly visits to support the service following our feedback.

However, the service had made some improvements to their governance and management arrangements since the last CQC inspection. This included the provider’s service improvement plan. As improvements had been made since our last assessment to people’s personal evacuation plans, and care plans were being reviewed and updated as needed. Training was provided to staff where shortfalls had been identified, and staffing levels were reviewed through a dependency tool. Daily checks were now being completed of people’s food and fluids documentation, their repositioning, and people’s specialist equipment such as mattresses.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.