Campania

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• 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

The manager had introduced comprehensive systems to give better oversight of what was happening within the service. Staff told us they felt supported and enjoyed their work. People said the home was well run. At our last assessment we found the provider’s quality assurance systems were not identifying shortfalls relating to risk assessments, the recording of incidents and accidents, notifications and Mental Capacity Assessments. This was a breach of regulation 17 (Good Governance). At this inspection enough improvement had been made and the service was no longer in breach of the regulation. At our last assessment we found notifications had not always been made around incidents and safeguarding. This was a breach of regulation 18 (Notifications). At this inspection the service was no longer in breach of the regulation.

This service scored 75 (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.

Staff we spoke with were knowledgeable about people. Staff demonstrated skills and knowledge about different areas such as safeguarding, the Mental Capacity Act and Deprivation liberty of safeguards. There was positive feedback about the service, its aim and objectives and the support given to people. Staff told us they understood risks to people and how to mitigate those risks. One staff member told us “We offer choices explaining what might happen or the consequences of different choices. For example, a person who is diabetic might want a biscuit. I would explain the consequences and then offer ways to support them like getting some diabetic biscuits”. Staff said they understood they needed to seek verbal consent before they supported people with daily tasks such as supporting with meals and personal care. Where people refused support, this was recorded. One staff member told us “We respect people can make unwise decisions. Some people have capacity, don’t have capacity for some decisions and some people have fluctuating capacity. For example, one person does not have capacity about their finances but can make daily choices about meals and activities”.

There were systems in place to monitor the quality and safety of the service. Audits were being carried out at provider and service level. During our assessment we saw evidence the manager was working to address the shortcomings identified in the previous assessment, this included changes to processes for the recording and monitoring of accidents and incidents, changes to staff handover communication and reviewing care plans. However, the service improvement plan we saw had not been updated to reflect the work the manager had implemented since February 2024. We saw evidence of risk reduction work in partnership with agencies to support a person to move to more independent accommodation that better meet their needs, reducing the risk to themselves and other’s. During the assessment we found some risk assessments had not been completed. However specific protocols around how to manage a person’s diabetes for example, had been recorded in the care plan and gave guidance for staff to follow. We informed the manager of our findings during the assessment, and they took immediate steps to address the gaps we identified. Since the last assessment the manager has been reviewing people’s care plans including Mental Capacity Assessments. The service had improved their mental capacity and best interest decision making assessment process from the last assessment. However, we identified two specific mental capacity decisions had not been completed where people may put themselves at risk of harm. The manager started to address the shortfalls identified during our assessment. Where people were being deprived of their liberty, referrals had been made to the local authority. The manager monitored Deprivation of Liberty referrals and any conditions attached to a person’s authorised Deprivation of Liberty. We found Notifications were being submitted appropriately and in a timely manner.

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.