Updated 15 February 2024
The assessment was completed between 4 March 2024 and 30 April 2024. On-site visit took place on 4 and 6 March 2024. We completed this responsive assessment to check on the issues identified at the last inspection. During this assessment, we found three breaches of the legal regulations in relation to management of medicine, recruitment and selection, and governance. We identified the provider did not always follow their quality assurance systems effectively to assess, monitor and mitigate risks relating to the health, safety and welfare of people, the service and others. The provider did not always maintain accurate and complete records relating to the management of medicine; necessary information as part of provider’s recruitment processes; staff training and some people’s care and support records. However, we also found the registered manager and the staff team have been working together to help make changes needed in the service and at the same time, to ensure people continued receiving the care and support they needed. We found the registered manager made changes to the service that had positive impact to people and their outcomes including better teamwork, support to each other and communication with professionals, review of daily care and support, activities and records. The last rating for this service was inadequate and there were multiple breaches of regulations with enforcement action taken. During this assessment the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.