Sedgeborough House improved from Requires Improvement to Good across all five key questions following significant management restructuring and strengthened governance, audit, and care planning processes. Minor gaps remained around following up missed MAR signatures and completing staff appraisals, but no regulatory breaches were identified.
Concerns (2)
minor
Medication management
: “the service needed to ensure they followed up on missed staff signatures on the medicine administration records (MARs) with the individual staff members to drive improvements”
minorSupervision / appraisal: “Appraisals had not yet commenced as the new management team had restarted the appraisals process since commencing at the service, but we noted forthcoming appraisals had been planned.”
Strengths
· People reported no missed or late calls and praised continuity of care staff.
· Comprehensive risk assessments completed for every person using the service, kept up to date.
· Improved recruitment processes with full pre-employment checks including DBS completed before staff start.
· Monthly medication audits introduced with consistent completion by registered manager or care coordinators.
· Strong person-centred care with people involved in care planning and regular reviews.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Staffing levels and recruitmentGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
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
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Planning and promoting person-centred, high-quality care and support; duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood