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Date of assessment 23 June 2025 to 25 July 2025. This inspection was carried out in response to concerns raised about personal care provided to a service user and because the service had not yet been inspected. We looked at all key questions and quality statements under the domains of Safe, Effective, Caring, Responsive and Well-led. We found people using the service were safe and protected from abuse and avoidable harm. Environments were actively monitored by staff to ensure ongoing safety and wellbeing for people using the service. The service made sure staff were qualified and had access to the necessary training required for their role. There were recruitment checks to verify staff were suitably employed prior to starting in the role. Systems and processes were in place to support safe and effective transition into the service. Staff and teams worked well together and there was evidence of effective partnership working to ensure people’s needs were being met. Staff demonstrated an awareness of kindness, dignity and respect for the people they worked with. People using the service were actively listened to and had regular opportunities to provide feedback on their care experiences. The provider had a clear shared vision and strategy in place. Leadership was inclusive and promoted a culture of openness and honesty, which was reflected in the day-to-day operations of the service. However, we identified risks around people’s medicines which had not been identified by the provider. We also found a Mental Capacity Assessment (MCA) for a person had not been completed appropriately. For example, conflicting information within the documentation made it unclear whether a person had capacity or not to make a specific decision in relation to their medicine administration. When highlighted to the provider they took immediate action and provided evidence to support this. The audits completed by the provider had also not identified the concerns we found. Therefore, we had concerns about the effectiveness of audits. Some staff also raised concerns about their well-being due to working long shifts over several days without regular breaks.
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