Woody Point

Right Support: People were not always cared for and supported in a secure, clean, well-equipped, well-furnished, and well- maintained environment that met their sensory and physical needs. We identified concerns that had not been fully risk assessed and mitigated against which put people at risk of harm.

There were enough staff to meet people's needs. Staffing challenges including personnel changes, retention and recruitment had impacted on continuity of care and there were instances of people's routines being affected. To maintain safe staffing levels the registered manager had been covering care shifts instead of overseeing the service. The provider was taking action to address this through active recruitment and had recently employed two members of staff and had plans for further senior level support.

Overall people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; but there were inconsistencies in the policies and systems in the service to support this practice. Although the outcomes for people were appropriate the management team were not always confident in reflecting shared decision making and documenting best interest decisions. We signposted the registered manager to access support in this area.

Right Care: There was a calm and relaxed atmosphere in the service. Staff were respectful and supportive in their interactions with people. Where people required support with personal care this was provided in a discreet way and promoted people's dignity and privacy.

Right Culture:

The provider's governance arrangements did not provide assurance the service was well led. Systems and processes to oversee the safety and quality of the service were not robust and effective. They had not identified the shortfalls we found during our inspection and regulatory requirements were not always being met.

The registered manager's responsibilities were too great and this had impacted on their oversight of the service. In addition to covering care shifts at Woody Point they supported the provider's other managers nearby, who were new to the role. The provider's representative were not based locally in the area and acknowledged that a more visible presence was needed to support the registered manager and had plans to address this.

The registered manager and provider's representative were open and honest about the shortfalls at the service. They engaged with the inspection positively and demonstrated a commitment to making any necessary improvements.