Updated 16 August 2024
Date of assessment 29 August to 13 September 2024. The service is a residential care home, supporting up to 21 older people. There were 13 people living at the service at the time of the assessment. The assessment was carried out to follow up on a warning notice issued in February 2024 relating to governance. The service had made significant changes in leadership roles and procedures since the last assessment. We found sufficient improvement had been made in most areas detailed within our warning notice however, other shortfalls were identified, and this meant the service remained in breach of the regulation relating to governance. At this assessment, the rating for this service was requires improvement. People’s risk assessments were not always updated to ensure staff had access to accurate information about how to manage risks to people. Incidents and follow up actions were recorded; however, this was not always well documented. Medicine errors were not well documented or processed in line with the provider’s policy. Recruitment processes did not adhere to best practice guidance or the provider’s own policies. Governance systems still did not effectively assess, monitor, or improve safety or quality of care; however, improvements had been made since the last assessment. Staff understood people’s needs and delivered care with dignity and respect. People were treated with kindness and supported to have choice and control over their daily lives. The service valued staff and proactively supported their well-being. People received person-centred care and support. The service provided information to people in a way they could understand, and people were able to give feedback. Staff understood the service’s visions and values and felt well supported by leaders. The service collaborated with staff and partners, and there was a clear focus on continuous learning and improvement. We asked the provider for an action plan in response to concerns found during this assessment.