Updated 4 July 2024
Date of Assessment – 10 and 12 April 2024. This was a responsive assessment based on information CQC had received about the service. During this assessment, four regulatory breaches were identified in respect of safe care and treatment, staffing, the need for consent and good governance. People’s needs and risks were not adequately assessed or managed. As a result, people’s care was not always managed safely to mitigate risks to their health and wellbeing. Learning from accidents and incidents was not always implemented effectively to prevent similar events occurring again. Mental capacity legislation designed to protect people’s right to consent was not properly understood or applied. Staff received adequate training but some felt additional dementia training was needed. Staff supervision and appraisals were not up to date to monitor and support staff practice. There were governance systems in place to monitor the quality and safety of the service however these were not fully robust. Staff were recruited safely and the number of staff on duty on the day of the assessment was adequate. People were protected from the risk of abuse. People received their medicines and had access to regular GP support. People had enough to eat and drink and a choice. Staff were observed to be kind, caring and compassionate. The culture of the service was open and transparent. There was service improvement plan already in place at the time of our assessment.