The Four Seasons Trust Limited - 33 Abbotswood

The inspection was prompted in part, because of the length of time since the last inspection, and to check if the provider had made the necessary improvements since our last inspection.

At our last inspection in December 2019, we rated the service requires improvement in the safe, responsive and well-led key questions and overall.

At this inspection, we found breaches of legal regulations in relation to safe care and treatment, staffing and governance.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence, and good access to community facilities. We found people received care and support in accordance with its principles.

During this assessment, we found processes to ensure risks to people were assessed and mitigated, were not always effective and prompt action was not always taken to mitigate identified risks. Risk assessments were not always robust enough and did not provide the necessary information about risk and how to reduce this.

The provider’s monitoring systems were not robust as they had failed to identify and address the concerns we found during our inspection. Records were disorganised, and inspectors were unable to access some key documents during the visit. Some records were out of date, and the provider could not demonstrate that these were subject to regular review.

Although incidents and accidents were recorded, there was no analysis to identify trends and themes and systems did not support learning from these events. Although the registered manager told us they took complaints seriously, these were not recorded.

Training records showed that staff had not received regular training across a range of required subjects. This meant we could not be sure they had the necessary skills to provide care to people. Although the management team told us training had taken place, they were unable to provide evidence of this.

There were systems to protect people from the risk of infection and cross contamination. Staff followed good practice. However, infection prevention and control audits were not recorded so we could not be sure these happened regularly. The home was clean, but some areas required maintenance.

There were systems in place for the safe recruitment of staff. People and their relatives were involved in their pre-admission assessment, care planning and the management of individual risks. Staff spoke favourably of the management team and felt listened to and consulted.

People received their medicines safely and as prescribed.