Focused inspection of Safe and Well-led found sufficient improvement since the previous inspection, with breaches of regulations 12 and 19 no longer present. The overall rating improved from Requires Improvement to Good.
Strengths
· Improved recruitment procedures with full employment histories, references, right to work documents and DBS checks in place
· Risks to people had been assessed with care records updated to provide guidance for staff
· Medicines managed safely with MAR charts, training and competency assessments
· Staff completed shadowing and observation visits before working independently
· Strong safeguarding awareness and training, with annual refreshers for longer-serving staff
Quality-Statement breakdown (11)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot 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 requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering, which achieves good outcomes for peopleNot rated
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsNot rated
well-led: Working in partnership with othersNot rated
well-led: How the provider understands and acts on the duty of candourNot rated