First inspection of this newly registered supported living service rated Good overall but Requires Improvement in well-led due to recent management changes, prior ineffective governance, and inconsistent supervision. Care delivery was safe, person-centred and compassionate, with the new manager already addressing shortfalls.
Concerns (6)
moderate
Leadership
: “Relatives and staff told us there had been a lack of consistency in how well the service had been managed.”
moderateGovernance: “Prior to the new manager taking up post, governance processes had not been effective been in identifying shortfalls.”
moderateStaffing levels: “there had been staffing problems a few months ago and many staff had left... this had been a difficult time for their loved one as they had to get used to a lot of new faces”
moderateSupervision / appraisal: “they received support in the form of supervision, however they said due to the changes in the structure of the management team this had not been consistent.”
minorCommunication with families: “Relatives said that sometimes communication between staff and them could be improved.”
minorPerson-centred care: “One relative felt the activities their loved one did could be expanded and be more diverse.”
Strengths
· Person-centred care promoting dignity, privacy and human rights
· Staff knew people well and supported individual communication needs
· Effective safeguarding systems with appropriately trained staff
· Safe medicines management following STOMP principles
· Robust infection prevention and control measures including PPE and COVID-19 testing
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersNot rated