First inspection of this extra care service rated Good across all five key questions, with people receiving safe, person-centred care from a kind and well-supported staff team. Only minor issues were found with recruitment file gaps and earlier medicines concerns, both of which had been addressed through audits and management action.
Concerns (2)
minor
Staff training
: “we found minor gaps in two staff files where further details were needed. We discussed this with the registered manager and the matter was fully rectified during the inspection.”
minorMedication management: “the management team had found concerns with the safe management of medicines. Medicine practices were closely reviewed and action was taken to promote improvements.”
Strengths
· Kind, respectful staff who promote independence and dignity
· Safe medicines administration with regular audits and clearly completed MARs
· Robust infection prevention and control with PPE access and COVID-19 protocols
· Thorough risk assessments and individual emergency/evacuation plans
· Person-centred care plans reflecting people's backgrounds, cultural and religious needs
Quality-Statement breakdown (24)
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: Staff working with other agencies; supporting people to access healthcare servicesNot 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: Supporting people to develop and maintain relationships and take part in activitiesNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Promoting a positive, person-centred, open and empowering cultureNot rated
well-led: Managers and staff understanding roles, quality performance, risks and duty of candourNot rated
well-led: Engaging and involving people, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated