The Spinal Unit Action Group

We carried out a site visit to the home 28 February 2025, with the remainder of the assessment being conducted offsite. The assessment was prompted in part due to concerns received about people’s safety. A decision was made for us to inspect and examine those risks. We assessed a total of 15 quality statements from the safe and well-led key questions.

There was a registered manager in post, however they were on planned leave at the time of our assessment site visit, the deputy manager assisted us during the visit, and we gathered further information from the registered manager on their return.

We found a breach in regulation in relation to governance. The provider had not established consistent and effective governance systems and processes. There was a lack of regular checks and audits to assess, monitor and improve the quality and safety of the service.

Safety checks of the environment and equipment had not always been carried out at the required intervals and some checks and audits did not always fully review areas of potential risk. The providers formal process for staff supervisions and appraisals was not followed to enable staff to discuss and identify any training needs, their performance and areas for development. However, staff told us they felt well supported on a day-to-day basis. The provider had not developed a service improvement plan (SIP) to address any areas for improvement including those identified by other agencies.

The overall rating is requires improvement.

We have asked the provider for an action plan in response to the concerns found at this assessment.