Updated 7 March 2024
We carried out an assessment of this service to follow up on some concerns we had received. We looked at 18 quality statements. The assessment included site visits on 16 and 19 April, and 1 May 2024. We found systems were not effective in ensuring people received safe care and treatment. We identified significant concerns in relation to medicines practices and people had not always received their medicines as prescribed. Safeguarding procedures were in place but there was limited evidence of learning from previous incidents. There were not always enough suitably trained staff to meet people’s needs, which resulted in care being task focussed. Some people were left waiting for unacceptable periods for support with their personal care and continence needs. This meant people’s dignity was not consistently promoted. There were some organised activities available at the home, but we noted there was inequity in the support available to people. Monitoring of people’s food and fluid intake was poor, so we could not be assured people had always had enough to drink or food that met their needs. Care plans and risk assessments contained gaps in significant information. Quality assurance systems were not robust, as they had either not identified, or in some cases, not effectively addressed the issues we found on inspection. We observed some positive interactions between staff and people who used the service. Aspects of infection prevention and control practice needed improvement, but the home was generally clean and well-maintained. Staff spoke positively about the new registered manager, and the management team told us they were keen to address the issues identified. We identified five breaches of regulation in relation to medicines, staffing, nutrition and hydration, person centred care, and governance. We have asked the provider for an action plan in response to concerns found at this assessment.