St Oswalds

Although managers investigated incidents, risks to people’s health were not always fully assessed or mitigated, which increased the potential for harm. For example, for people living with asthma or chronic obstructive pulmonary disease (COPD) and epilepsy, there was limited guidance on recognising changes in condition or actions to take in the event of an emergency.

The provider carried out checks of the physical environment; however, these did not consistently identify areas requiring attention. This included environmental risks, missing window restrictors, and some infection prevention and control (IPC) concerns.

People were generally protected and kept safe, and staff demonstrated an understanding of risk management. However, facilities and equipment did not always meet people’s needs. The home had malodorous smells which was later addressed by the provider. There were sufficient numbers of staff with the appropriate skills, qualifications, and experience. Despite this, managers did not consistently ensure staff received training and regular appraisals to support the delivery of high-quality care. Medicines were not always managed safely; however, people were involved in planning any changes to their medication.

People were involved in assessments of their needs, and staff reviewed these assessments while considering people’s communication, personal and health requirements.

People had sufficient food and drink to maintain their health. Staff worked effectively with other agencies involved in people’s care to achieve positive outcomes and ensure smooth transitions between services. Staff ensured people understood their care and treatment to enable informed consent. Where people lacked capacity, staff involved those important to them and made decisions in their best interests.

Staff respected people’s privacy and dignity, treated them as individuals, and supported their preferences. People were encouraged to maintain relationships with family and friends and had choice in how their care was delivered. Overall, people were treated with kindness and compassion; however, some relatives reported further improvements were needed within the environment and to the care and support needs for people.

People, relatives and healthcare partners felt comfortable to give feedback and were confident the provider took it seriously and acted on it.

Leaders were visible and supportive, helping staff develop in their roles. Staff felt able to provide feedback and reported being treated fairly, without bullying or harassment. Staff understood their roles and responsibilities, and managers engaged with the local community to deliver effective care. The provider demonstrated support for staff wellbeing.

Although the provider had monitoring and assurance checks in place, these were not always effective in identifying and addressing the issues identified during the inspection.