Updated 13 February 2024
Date of assessment 22 February to 16 April 2024. This is the first rating for this location. We found 1 breach of the legal regulations in relation to good governance. The provider had an established quality assurance system used across all of its homes. These systems and audits were not always effective in identifying or addressing shortfalls in recruitment records and medicines management. However, we found no evidence to suggest people had been adversely impacted by this. We have asked the provider for an action plan in response to our concerns. Care plans to guide staff about the care people needed were not always person-centred. The provider had appropriate processes to help safeguard people from abuse. The provider investigated and reviewed falls and other incidents. They had recently developed an electronic system to enable managers to gather better information to help identify trends and learn lessons. The home was clean and well-maintained. The provider completed checks and managed risks to maintain a safe environment. Staff supported people to have enough to eat and drink, and to access healthcare. The provider followed the requirements of the MCA, including applying for DoLS authorisations for relevant people. The home had developed partnership arrangements with the local community, such as the church and school.