Core Prospects Limited - 37 Sandringham Crescent retained an overall Good rating following a focused inspection of safe, effective and well-led domains, with safe and well-led remaining Good. The effective domain declined to Requires Improvement due to gaps in mental capacity assessments, incomplete care planning for a recently admitted person, and shortfalls in staff supervision records and training matrix maintenance.
Concerns (6)
moderate
Consent / capacity
: “for people with additional needs, the provider had not always taken appropriate action to ensure their capacity to make decisions was assessed and recorded.”
moderateCare planning: “the support plan and risk assessment had not been updated after significant events including behaviour that challenged the service.”
moderateCare planning: “the provider had not always fully assessed the needs of a recently admitted person who had left the service at the time of our inspection.”
minorRecord keeping: “the provider's training matrix had not been updated to reflect all the training staff had received.”
minorSupervision / appraisal: “they had not completed the four staff supervision sessions in the last year that they aimed for.”
minorMedication management: “the MAR for a person who had recently left the service did not always contain a full record of refusals or other failure to receive medicines.”
Strengths
· People's medicines were safely managed with appropriate risk assessments and secure storage.
· Staff were recruited safely with well-organised recruitment processes including DBS checks and three references.
· Robust personal emergency evacuation plans (PEEPs) were in place for all people.
· The provider maintained good safeguarding systems and reported incidents to the appropriate local authority.
· People spoke positively about staff, describing them as 'very nice and very helpful'.
Quality-Statement breakdown (17)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with others: Continuous learning and improving careGood