Updated 7 January 2025
Date of assessment: 14 January to 14 February 2025. The provider did not always assess or manage the risk of infection. We observed some equipment was rusty and worn and could not be effectively cleaned. Some pressure relieving equipment was seen to be unclean with ripped protective covers. Environmental risks had not always been identified. Smaller windows on the ground and first floor had not been effectively risk assessed to ensure there was not a risk to people who could potentially climb out or fall from height. Some people’s medicine care plans contained very limited or no information. Care plans did not contain sufficient information for people who required insulin to manage their diabetes. The registered manager told us these were updated following feedback to ensure all relevant information was included. There were clear governance procedures in place however these had not always been effective. For example, records were not always completed, and this had not been highlighted in audits. This meant it was not always clear if people had been supported in line with their care and support needs or that their health needs had been met. Care plans gave guidance to staff on how they were to promote people’s independence and enable them to have choice and control over their own care and support. However, some care plans did not make it clear how people needed to be supported, and daily notes did not evidence that staff were supporting people in line with their assessed needs. Recruitment procedures for staff were safe and robust. Staff received training that was suitable for their role. Staff were positive about the training they had received. Safeguarding procedures were in place and robust. Staff had a good understanding of safeguarding and knew how to raise concerns if they needed to. The provider was in breach of 2 legal regulations relating to safe care and treatment and good governance.