Updated 20 May 2024
Date of assessment 24 May 2024 to 16 July 2024. This assessment was carried out as the service had not been previously rated. Overall, we looked at 33 quality statements in safe, effective, caring, responsive and well led. We found 2 breaches of the legal regulation in relation to safe care and treatment and good governance. This was in relation to medicines optimisation where the systems and processes in place were not effective to support medicines optimisation and provide care and treatment in a safe way. The systems and processes had also not been fully embedded to monitor and improve the quality of the service. Care plans and risk assessment did not always provide enough detail to keep people safe and did not consider nationally recognised evidence-based guidance. The manager took steps to address this during the assessment. However, we found staff knew how to treat people with kindness, compassion, dignity and respect. Staff and leaders demonstrated a positive compassionate and listening culture. People were being supported by other services and professionals. Staff were able to tell us how to keep people safe from harm and abuse and followed good infection, prevention and control (IPC) practices. Staff and teams worked well together. Care plans identified areas of individualised support needed and considered people’s protected characteristics, including religion, cultural needs and preferred pronouns. Staff responded to people’s immediate needs. The organisation looked after staff wellbeing and staff had received training relevant to their role. We have asked the provider for an action plan in response to our concerns.