Updated 28 March 2024
Date of assessment 29 April 2024 to 17 June 2024 This assessment was carried out in relation to people contacting CQC with concerns about the service. Overall, we looked at 12 quality statements in Safe and Well Led. During this assessment we found people were safe and had access to equipment to remain safe. Medication was provided to people and recorded accurately. There were clear policies and procedures in place. Staff worked with other services to ensure people’s needs were being met and demonstrated a good understanding of people's individual needs. Recruitment processes ensured staff had been recruited safely. Staff were trained to meet people’s needs and showed a good understanding of equality, diversity and inclusion. Staff told us they received support to do their jobs. However, staff told us there were not enough staff during medicine administration and changes in leadership had affected them. People had not always been involved in their care plans and one person had not been repositioned in line with their care plans. Some of the audits completed by the provider were not effective and had not identified some of the concerns we found. Improvement was still needed in relation to keeping care plans up to date and accurate to provide safe care and treatment for people. We found 1 breach of the legal regulation in relation to good governance. This was in relation to people’s care plans not being up to date and accurate. Audits were not effective and had not identified the concerns we found. We have asked the provider for an action plan in response to our concerns.