Updated 18 March 2024
Date of assessment 26 March to 26 April 2024. This assessment was carried out as the service was previously rated as inadequate and in special measures. Overall, we looked at 17 quality statements in Safe and Well Led. Overall the service is rated as requires improvement. During this assessment we found that improvements had now been made. We found that people were safeguarded, risks to people were safely managed and records used to monitor and review people’s care were fully completed and up to date. There were now safe and effective infection control processes which ensured people were protected from the risk of infection. Risks to the premises were now being safely managed and learning and improvement had taken place. There were now processes in place for safe and effective staffing and systems and processes were in place to allow people's safe transition into the home. There had been improvement in the culture and people were able to speak up and have their voices heard. The service employed a diverse workforce and there was now good collaboration with partnerships and communities. There had been some improvement in medicine optimisation. However, we found although there had been some improvement in the management of medicines, some information was not always available to support staff to administer regular but variable dose medicines. We found weaknesses with the controlled drugs (CD) records and whilst medicines optimisation audits had been undertaken by the provider, the audits had not identified our concerns with the controlled drugs (CD) storage and records. We also found the provider had not requested a reference from previous employment where the person had worked in care. This was an isolated incident and the provider had sourced a professional and character reference for the staff member. The provider took steps and requested the reference immediately when notified. We found 3 breaches in relation to good governance.