Updated 18 March 2024
We carried out our on-site assessment on 23 April 2024. Off site assessment activity started on 24 April 2024 and ended on 22 May 2024. We looked at 5 quality statements; safeguarding; involving people to manage risks; safe and effective staffing; medicines optimisation; and governance, management and sustainability. The provider’s systems, processes, and practices to protect people from abuse were not always effective. One person’s risk assessment was not robust enough to keep them and other people safe. Some medicines records needed improvement. The provider’s quality assurance audits and checks had failed to identify these issues. We have identified a breach of regulation in relation to safeguarding during this assessment. We requested an action plan from the provider. The service was well-staffed with knowledgeable nurses and care workers. They understood most people’s needs and how best to support them. Staff were well-trained and followed people’s care plans and risk assessments to help ensure they provided good quality care. The registered manager was committed to continually improving the service and acted immediately to address the shortfalls we found during our assessment.