Focused inspection found sufficient improvements since the previous requires improvement rating, with the provider no longer in breach of regulations 12 and 17. Safe, Responsive and Well-led were all rated Good, lifting the overall rating to Good.
Concerns (5)
minorInfection control: “Appropriate management plans were put in place following an outbreak at the service to minimise the impact on people.”
minorPerson-centred care: “Feedback from people was mixed about the activities and opportunities available to them. Whilst some people were very active, others felt opportunities were limited.”
minorSafeguarding: “A concern was raised with us during the inspection. A safeguarding concerns was raised with the local authority.”
minorOther: “People raised concerns about the safety and security of the building and grounds. The registered manager confirmed work to repair the entrance gate had been planned.”
minorStaffing levels: “On-going recruitment was taking place to fill current vacancies and increase flexibility.”
Strengths
· New service model introduced providing structured staffing arrangements and improved support plans
· Comprehensive assessments providing clear direction for staff and reducing risk
· Personalised care tailored around people's likes, wishes and preferences
· Safe management and administration of prescribed medicines
· Safe recruitment procedures with structured rota offering consistent support
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: How the provider understands and acts on the duty of candour; managers and staff being clear about their roles; continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staff; promoting a positive person-centred cultureGood