Updated 2 December 2024
Date of Assessment: 10 December to 20 December 2024. We assessed this service because of increased risk related to concerns raised to the local inspection and assessment team. We assessed all of the quality statements in Safe and Well-Led. The service is a residential care home providing support to 74 older people and people living with dementia. We found 1 breach of the legal regulations in relation to safe care and treatment. Staff did not always mitigate risks to people's health and safety. People’s care was not always delivered in line with care plans. The provider’s governance systems had identified areas for improvement and plans were in place to address these. Managers investigated incidents and we discussed how lessons learned are identified and communicated to the staff team. The facilities and equipment met the needs of people and were clean and well-maintained with any risks mitigated. Managers made sure staff received training and regular appraisals. Staff managed medicines well and involved people in planning any changes. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported. Staff understood their roles and responsibilities. Managers worked with local community-based services to deliver care and were receptive to new ideas. The provider had introduced new systems and processes to support the development of a culture of continuous improvement with staff given time and resources to try new ideas. Time needs to be given to embed new systems so that improvement can be evidenced. We have asked the provider for an action plan in response to the concerns found at this assessment.