The Dales Care Home improved sufficiently to exit Special Measures, with the overall rating moving from Inadequate to Requires Improvement and breaches of Regulations 12, 13 and 19 resolved. However, the provider remained in breach of Regulation 17 (Good governance) due to inconsistently maintained oversight systems, including unaddressed fire safety risks and gaps in agency staff assurance.
Concerns (6)
criticalGovernance: “Systems for assessing and monitoring the quality and safety of the service had not been consistent or always applied effectively.”
criticalOther: “staff were still in the practice of wedging open the fire doors on people's bedrooms. This prevented them from automatically closing and offer people protection in the event of a fire.”
moderate
Governance
: “some of the governance systems had not been consistently maintained or had not always been effectively implemented.”
moderateStaff competency: “The provider could not always be assured that agency staff were working at the home safely.”
moderateSafeguarding: “One area of the home was accessible to people when it was not safe for them to do so. This was a risk known to staff which had not been addressed.”
minorStaffing levels: “The provider told us that they had struggled to recruit a full staff team. They were making significant use of agency staff to ensure enough staff were present at the home.”
Strengths
· Friendly and relaxed atmosphere with kind, thoughtful interactions between staff and people living at the home
· Person-centred care planning focused on outcomes, needs and risks
· Improved systems for assessing, recording and mitigating risks in people's care and accommodation
· Medicines stored, recorded and administered safely with effective checking system
· Improved infection prevention and control, with COVID-19 vaccination requirements met
Quality-Statement breakdown (11)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot 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
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 candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated