Updated 14 March 2024
We carried out an assessment of this service to follow up on concerns we had following incidents the service told us about. We looked at 18 quality statements across 5 domains. The assessment included site visits on 15 April, 2 May, and 7 May 2024. We found breaches of the legal regulations in relation to safe care and treatment, medicines, and governance. We identified issues with the environment including unnecessary restrictions and residents having access to areas of the home and equipment which put them at risk of harm. The service had not always learnt from incidents or took action to fully mitigate the potential risk of harm. When accidents and incidents happened, the service did not always evidence they had fulfilled their responsibilities under duty of candour. Medicines management and practice did not follow the policy in place, and we could not be assured that all staff were assessed as competent in the management and administration of medicines. Risk assessments were not always in place or were generic and required more information. Recording of people’s food and fluids was in place but these were not always effectively reviewed and actioned to ensure people received the amount required to meet their needs. Whilst mental capacity assessment documentation was in place this was often of a poor standard and not always reflective of the person’s current presentation. The home was generally clean and well-maintained. Issues found on inspection had not been identified by the provider as part of their routine checks or audit processes. The service was responsive to the feedback provided as part of the inspection and had taken immediate action to address issues within the environment. There had been a recent change in the management and staff team and whilst improvements had been made more work was needed. Staff told us that they had seen a positive change in the culture of the service and felt able to raise concerns which would be listened to and addressed.