Updated 3 June 2024
Date of assessment: 23 July 2024 to 31 July 2024. We completed the assessment in response to concerns we received regarding managing medicines, moving and handling, managing safeguarding concerns and following guidance from health professionals. We assessed elements of the key questions safe, effective and well-led. People were protected from the risk of abuse and the risk of mistakes being repeated due to effective monitoring of incidents. Staff assessed people's needs and risks and understood people's personal preferences. People were supported by staff that had been recruited using safe recruitment processes. The provider made sure people were kept safe from environmental risks as they had robust health and safety management systems. Staff reviewed people's needs regularly and used appropriate methods to make sure care was evidenced based. Staff worked together and with external agencies to make sure people's wider health and wellbeing needs were met. The provider monitored outcomes to identify where improvements were required. Staff understood their responsibilities under The Mental Capacity Act, 2005 and sought people's consent before any caring task. The provider had appointed a new manager who planned to apply to be registered with the CQC. The manager was aware of risks and we could see a clear system to monitor performance. Staff, people and relatives were positive about management. Whilst the manager and provider were aware of recent concerns and shortfalls, the action plan to address these was still in progress and some aspects of governance were not embedded. However, improvements were required to make sure medicines were managed safely and we found 1 breach of the legal regulation. We have asked the provider for an action plan in response to the concerns found at this assessment.