Updated 22 May 2024
Date of assessment 30 May to 10 September 2024. At our last inspection the provider had breached the regulations relating to staffing and good governance. The provider was no longer in breach. The provider had enough staff and recruited new staff safely. Medicines administration records (MARs) were accurate and evidenced the medicines people had received from care staff. However, no MARs were available for topical medicines, such as creams. This was also an issue at the last inspection. Following our visit to the service the registered manager confirmed these were in place. Medicines competency assessments were also out of date. There were systems to record and review incidents. Although care staff had completed safeguarding training as part of the Care Certificate, they had not completed specific safeguarding training. Partners also felt the service could engage more proactively with safeguarding. Care plans usually contained person-specific risk assessments. Professionals had input into risk management. However, care plans were not always available for some people with specific health needs. The provider confirmed they would act on this immediately. The management structure and on-call arrangements were unclear in relation to conflicting information about some staff roles, oversight arrangements in the registered manager's absence staff access to some records. The provider’s website was not showing the current rating and advertising for services which the provider was not registered for. This has since been addressed. The provider had quality assurance processes, comprising of audits and checks on the service. The completed audits lacked detailed information about the findings, as well as containing little reflection about areas for improvement and lessons learnt. The provider’s service improvement plan identified future development plans for the service. However, it lacked specific timescales for delivering the improvements.